带血管腓骨复合灭活瘤骨修复节段性骨缺损
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摘要
目的探讨用带血管腓骨复合自体灭活瘤骨用于四肢长骨恶性肿瘤切除后节段性缺损重建临床结果。方法 2013～2018年间对8例(股骨远端4例,胫骨近端4例)长骨恶性骨肿瘤进行保肢手术,术时患者平均年龄(14±3.6)(10～21)岁。对肿瘤切除后肢体的节段性骨缺损用带血管自体腓骨复合自体灭活瘤骨进行重建。通过骨扫描评估移植腓骨的成活情况,通过X线片评估骨结合部的愈合情况。对患者随访进行肿瘤学和影像学结果的评估。国际保肢骨与软组织肿瘤学会93评分标准用于保肢后功能评估。结果术后平均随访42 (15～51)个月。4例采用游离腓骨瓣与自体灭活瘤骨复合,4例胫骨缺损采用同侧带蒂腓骨瓣局部转移与自体灭活瘤骨复合。肿瘤切除后平均骨缺损长度为(16.25±4.1) cm,移植腓骨平均长度为(18.8±3.8) cm。骨扫描结果证实所有移植腓骨均成活,自体灭活瘤骨和宿主骨之间的平均愈合时间分别为:股骨:(7.6±0.4)个月,胫骨:(8.4±1.5)个月。最终随访时的MSTS平均得分为95.5%。无感染和骨不连病例。4年以上随访患者肿瘤学结果:6例CDF (confinuous disease free),2例DOD (died of disease)。结论带血管的自体腓骨复合自体灭活瘤骨可用于长骨恶性肿瘤切除后节段性骨缺损的重建,带血管腓骨促进了自体灭活瘤骨与宿主骨之间的愈合,是复合生物重建获得良好功能结果的基础。
Objective To explore the clinical results of segmental defect reconstruction after long bone malignancy extremity excision with vascularized fibula autologous inactivation. Methods From 2013 to 2018,8 cases of long bone malignant bone tumors (4 cases of the distal femur and 4 cases of the proximal tibia) were treated with limb salvage surgery. The mean age was (14 ± 3.6) years (range: 10-21 years). The segmental bone defect of the limb after tumor resection was reconstructed with vascularized fibula autograft inactivation. Bone scan was used to assess the peroneal graft survival and X-ray film was used to assess the healing of the bone junction. All patients were followed up for oncology and imaging evaluation. The international society for the preservation of limb bone and soft tissue tumor 93 score standard was used for the evaluation of limb functions. Results The mean follow-up was42 months (range: 15-51 months). Four cases were combined with free fibula flap and autologous inactivated tumorous bone, and 4 cases with tibial defect were combined with local transplant of ipsilateral pedicled fibula flap.The average length of bone defect after tumor resection was (16.25 ± 4.1) cm, and the average length of transplanted fibula was (18.8 ± 3.8) cm. The results of bone scan confirmed that all transplanted tibia survived, and the average healing time of the autologous inactivated tumor bone and host bone were (7.6 ± 0.4) months in the femur and (8.4 ± 1.5) months in the tibia. MSTS averaged 95.5% at the final follow-up. There were no cases of infection or nonunion. Oncology results more than 4 years: 6 CDF, 2 DOD. Conclusions Vascularized fibula autograft combined with autoinactivated tumor-bone can be used for the reconstruction of segmental bone defect after long bone malignant tumor resection. The vascularized fibula promotes the healing between the autologous inactivated tumor bone and host bone, which is the basis for the biological reconstruction to obtain good functional results.
Objective To explore the clinical results of segmental defect reconstruction after long bone malignancy extremity excision with vascularized fibula autologous inactivation. Methods From 2013 to 2018,8 cases of long bone malignant bone tumors (4 cases of the distal femur and 4 cases of the proximal tibia) were treated with limb salvage surgery. The mean age was (14 ± 3.6) years (range: 10-21 years). The segmental bone defect of the limb after tumor resection was reconstructed with vascularized fibula autograft inactivation. Bone scan was used to assess the peroneal graft survival and X-ray film was used to assess the healing of the bone junction. All patients were followed up for oncology and imaging evaluation. The international society for the preservation of limb bone and soft tissue tumor 93 score standard was used for the evaluation of limb functions. Results The mean follow-up was42 months (range: 15-51 months). Four cases were combined with free fibula flap and autologous inactivated tumorous bone, and 4 cases with tibial defect were combined with local transplant of ipsilateral pedicled fibula flap.The average length of bone defect after tumor resection was (16.25 ± 4.1) cm, and the average length of transplanted fibula was (18.8 ± 3.8) cm. The results of bone scan confirmed that all transplanted tibia survived, and the average healing time of the autologous inactivated tumor bone and host bone were (7.6 ± 0.4) months in the femur and (8.4 ± 1.5) months in the tibia. MSTS averaged 95.5% at the final follow-up. There were no cases of infection or nonunion. Oncology results more than 4 years: 6 CDF, 2 DOD. Conclusions Vascularized fibula autograft combined with autoinactivated tumor-bone can be used for the reconstruction of segmental bone defect after long bone malignant tumor resection. The vascularized fibula promotes the healing between the autologous inactivated tumor bone and host bone, which is the basis for the biological reconstruction to obtain good functional results.
引文
[1]Weber KL.What’s new in musculoskeletal oncology[J].J Bone Joint Surg(Am),2005,87(6):1400-1410.
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[3]Enneking WF,Campanacci DA.Retrieved human allografts.Aclinicopathological study[J].J Bone Joint Surg(Am),2001,83(7):971-986.
[4]Thompson Jr RC,Pickvance EA,Garry D.Fractures in large-segment allografts[J].J Bone Joint Surg(Am),1993,75(11):1663-1673.
[5]Berrey Jr BH,Lord CF,Gebhardt MC,et al.Fractures of allografts.Frequency,treatment,and end-results[J].J Bone Joint Surg(Am),1990,72(6):825-833.
[6]Hornicek FJ,Gebhardt MC,Tomford WW,et al.Factors affecting nonunion of the allograft-host junction[J].Clin Orthop Relat Res,2001,382:87-98.
[7]Tsuchiya H,Wan SL,Sakayama K,et al.Reconstruction using an autograft containing tumor treated by liquid nitrogen[J].J Bone Joint Surg Br,2005,87:218-225.
[8]Moore JR,Weiland AJ,Daniel RK.Use of free vascularized bone grafts in the treatment of bone tumors[J].Clin Orthop Relat Res,1983,175(5):37-44.
[9]Croce F,Risorto M,Coviello M,et al.Vascularised fibula transplant:Technique,early results,indications and limitations[J].Ital J Orthop Traumatol,1986,12(4):447-454.
[10]Wood MB.Upper extremity reconstruction by vascularized bone transfer:Results and complications[J].J Hand Surg(Am),1987,12(3):422-427.
[11]Pollock R,Stalley P,Lee K,et al.Free vascularized fibula grafts in limb-salvage surgery[J].J Reconstr Microsurg,2005,21(2):79-84.
[12]O’Brien BM,Gumley GJ,Dooley BJ,et al.Folded free vascularized fibula transfer[J].Plast Reconstr Surg,1988,82(2):311-318.
[13]El-Gammal TA,El-Sayed A,Kotb MM.Microsurgical reconstruction of lower limb bone defects following tumor resection using vascularized fibula osteoseptocutaneous flap[J].Microsurgery,2002,22(5):193-198.
[14]Capanna R,Bufalini C,Campanacci C.A new technique for reconstruction of large metadiaphyseal bone defects:Acombined graft(allograft shell plus vascularized fibula)[J].Orthop Traumatol,1993,2(5):159-161.
[15]Gage AA,Baust JM,Baust JG.Experimental cryosurgery investigations in vivo[J].Cryobiology,2009,59(3):229-243.
[16]Nagle WA,Soloff BL,Moss AJ Jr,et al.Cultured Chinese hamster cells undergo apoptosis after exposure to cold but nonfreezing temperatures[J].Cryobiology,1990,27(4):439-451.
[17]Burton SA,Paljug WR,Kalnicki S,et al.Hypothermiaenhanced human tumor cell radiosensitivity[J].Cryobiology,1997,35(1):70-78.
[18]Enneking WF,Dunham W,Gebhardt MC,et al.A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system[J].Clin Orthop Relat Res,1993,286(1):241-246.
[19]O’Flanagan SJ,Stack JP,McGee HM,et al.Imaging of intramedullary tumour spread in osteosarcoma.A comparison of techniques[J].J Bone Joint Surg(Br),1991,73(6):998-1001.
[20]Fuchs B,Ossendorf C,Leerapun T,et al.Intercalary segmental reconstruction after bone tumor resection[J].Eur J Surg Oncol,2008,34(12):1271-1276.
[21]Brigman BE,Hornicek FJ,Gebhardt MC,et al.Allografts about the knee in young patients with high-grade sarcoma[J].Clin Orthop Relat Res,2004,421(4):232-239.
[22]Ihara K,Doi K,Yamamoto M,et al.Free vascularized fibular graft for large bone defect in the extremities after tumor excision[J].J Reconstr Microsurg,1998,14(6):371-376.
[23]Hornicek FJ,Gebhardt MC,Tomford WW,et al.Factors affecting nonunion of the allograft-host junction[J].Clin Orthop Relat Res,2001,382(1):87-98.
[24]Taylor GI,Miller GD,Ham FJ.The free vascularized bone graft.A clinical extension of microvascular techniques[J].Plast Reconstr Surg,1975,55(5):533-544.
[25]Yijima H,Tamai S,Ono H,et al.Vascularized bone grafts to the upper extremities[J].Plast Reconstr Surg,1998,101(3):727-737.
[26]Zaretski A,Amir A,Meller I,et al.Free fibula long bone reconstruction in orthopedic oncology:a surgical algorithm for reconstructive options[J].Plast Reconstr Surg,2004,113(7):1989-2000.
[27]Innocenti M,Abed YY,Beltrami G,et al.Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft:long-term results[J].Microsurgery,2009,29(5):361-372.
[28]Friedlaender GE,Tross RB,Doganis AC,et al.Effect of chemotherapeutic agent on bone[J].J Bone Joint Surg(Am),1984,66(4):602-607.
[29]Dick HM,Malinin TI,Mnaymneh W.A massive allograft implantation following radical resection of highgrade tumors requiring adjuvant chemotherapy treatment[J].Clin Orthop Relat Res,1985,197(8):88-95.
[2]Ortiz-Cruz E,Gebhardt MC,Jennings LC,et al.Theresults of transplantation of intercalary allografts after resection of tumors.A long-term follow-up study[J].J Bone Joint Surg Am,1997,79:97-106.
[3]Enneking WF,Campanacci DA.Retrieved human allografts.Aclinicopathological study[J].J Bone Joint Surg(Am),2001,83(7):971-986.
[4]Thompson Jr RC,Pickvance EA,Garry D.Fractures in large-segment allografts[J].J Bone Joint Surg(Am),1993,75(11):1663-1673.
[5]Berrey Jr BH,Lord CF,Gebhardt MC,et al.Fractures of allografts.Frequency,treatment,and end-results[J].J Bone Joint Surg(Am),1990,72(6):825-833.
[6]Hornicek FJ,Gebhardt MC,Tomford WW,et al.Factors affecting nonunion of the allograft-host junction[J].Clin Orthop Relat Res,2001,382:87-98.
[7]Tsuchiya H,Wan SL,Sakayama K,et al.Reconstruction using an autograft containing tumor treated by liquid nitrogen[J].J Bone Joint Surg Br,2005,87:218-225.
[8]Moore JR,Weiland AJ,Daniel RK.Use of free vascularized bone grafts in the treatment of bone tumors[J].Clin Orthop Relat Res,1983,175(5):37-44.
[9]Croce F,Risorto M,Coviello M,et al.Vascularised fibula transplant:Technique,early results,indications and limitations[J].Ital J Orthop Traumatol,1986,12(4):447-454.
[10]Wood MB.Upper extremity reconstruction by vascularized bone transfer:Results and complications[J].J Hand Surg(Am),1987,12(3):422-427.
[11]Pollock R,Stalley P,Lee K,et al.Free vascularized fibula grafts in limb-salvage surgery[J].J Reconstr Microsurg,2005,21(2):79-84.
[12]O’Brien BM,Gumley GJ,Dooley BJ,et al.Folded free vascularized fibula transfer[J].Plast Reconstr Surg,1988,82(2):311-318.
[13]El-Gammal TA,El-Sayed A,Kotb MM.Microsurgical reconstruction of lower limb bone defects following tumor resection using vascularized fibula osteoseptocutaneous flap[J].Microsurgery,2002,22(5):193-198.
[14]Capanna R,Bufalini C,Campanacci C.A new technique for reconstruction of large metadiaphyseal bone defects:Acombined graft(allograft shell plus vascularized fibula)[J].Orthop Traumatol,1993,2(5):159-161.
[15]Gage AA,Baust JM,Baust JG.Experimental cryosurgery investigations in vivo[J].Cryobiology,2009,59(3):229-243.
[16]Nagle WA,Soloff BL,Moss AJ Jr,et al.Cultured Chinese hamster cells undergo apoptosis after exposure to cold but nonfreezing temperatures[J].Cryobiology,1990,27(4):439-451.
[17]Burton SA,Paljug WR,Kalnicki S,et al.Hypothermiaenhanced human tumor cell radiosensitivity[J].Cryobiology,1997,35(1):70-78.
[18]Enneking WF,Dunham W,Gebhardt MC,et al.A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system[J].Clin Orthop Relat Res,1993,286(1):241-246.
[19]O’Flanagan SJ,Stack JP,McGee HM,et al.Imaging of intramedullary tumour spread in osteosarcoma.A comparison of techniques[J].J Bone Joint Surg(Br),1991,73(6):998-1001.
[20]Fuchs B,Ossendorf C,Leerapun T,et al.Intercalary segmental reconstruction after bone tumor resection[J].Eur J Surg Oncol,2008,34(12):1271-1276.
[21]Brigman BE,Hornicek FJ,Gebhardt MC,et al.Allografts about the knee in young patients with high-grade sarcoma[J].Clin Orthop Relat Res,2004,421(4):232-239.
[22]Ihara K,Doi K,Yamamoto M,et al.Free vascularized fibular graft for large bone defect in the extremities after tumor excision[J].J Reconstr Microsurg,1998,14(6):371-376.
[23]Hornicek FJ,Gebhardt MC,Tomford WW,et al.Factors affecting nonunion of the allograft-host junction[J].Clin Orthop Relat Res,2001,382(1):87-98.
[24]Taylor GI,Miller GD,Ham FJ.The free vascularized bone graft.A clinical extension of microvascular techniques[J].Plast Reconstr Surg,1975,55(5):533-544.
[25]Yijima H,Tamai S,Ono H,et al.Vascularized bone grafts to the upper extremities[J].Plast Reconstr Surg,1998,101(3):727-737.
[26]Zaretski A,Amir A,Meller I,et al.Free fibula long bone reconstruction in orthopedic oncology:a surgical algorithm for reconstructive options[J].Plast Reconstr Surg,2004,113(7):1989-2000.
[27]Innocenti M,Abed YY,Beltrami G,et al.Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft:long-term results[J].Microsurgery,2009,29(5):361-372.
[28]Friedlaender GE,Tross RB,Doganis AC,et al.Effect of chemotherapeutic agent on bone[J].J Bone Joint Surg(Am),1984,66(4):602-607.
[29]Dick HM,Malinin TI,Mnaymneh W.A massive allograft implantation following radical resection of highgrade tumors requiring adjuvant chemotherapy treatment[J].Clin Orthop Relat Res,1985,197(8):88-95.