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目的分析骨骺牵开保骺术在儿童股骨骨肉瘤保肢术中的疗效及应用价值。方法 2007年1月-2011年1月,收治6例股骨远端骨肉瘤患儿。男4例,女2例;年龄9～14岁,平均11.4岁。病程1～9个月,平均4.8个月。术前经穿刺或切开活检证实为骨肉瘤,其中成骨型骨肉瘤1例,软骨母细胞型骨肉瘤1例,骨母细胞型骨肉瘤1例,未明确细胞分类的骨肉瘤3例。根据Enneking提出的外科分期系统,其中ⅡA期1例,ⅡB期5例。术前采用新辅助化疗2个周期;首先行Ca adell骨骺牵开保骺术,牵开时间4～7 d,平均5.7 d;骨骺牵开保骺术完成1～2 d后行骨肿瘤切除,采用大段同种异体骨移植重建;术后进一步化疗并定期随访了解骨折愈合、下肢发育及局部和全身并发症等情况,并根据美国肌肉骨骼肿瘤学会(MSTS)评分系统评分及双膝关节活动度(range of motion,ROM)进行功能评定。结果术后发生切口浅表感染1例,经换药治疗后愈合;其余患儿切口均Ⅰ期愈合。6例均获随访,随访时间1～5年,平均2.5年;无明显肢体肿胀及疼痛等症状,未发生同种异体骨排斥反应及内固定物松动、断裂等。术后随访无肿瘤转移及局部复发等并发症发生。术后6～9个月干骺端骨性愈合5例,14个月1例;骨干部位均发生延迟愈合,术后12～48个月骨折端均有不同程度骨痂形成,但骨折线仍清晰可见。末次随访时患肢短缩1～3 cm 4例,3～5 cm 2例;发生代偿性脊柱侧弯3例,行走明显跛行2例;MSTS评分为(27.20±1.92)分,与术前(19.60±2.74)分比较差异有统计学意义(t=—4.12,P=0.00);患侧膝关节ROM为(127.00±17.89)°,与术前(109.00±12.45)°比较差异无统计学意义(t=—1.84,P=0.10),与健侧膝关节ROM(126.00±9.62)°比较差异无统计学意义(t=—0.11,P=0.92)。结论骨骺牵开保骺术可应用于骨骺尚未闭合的儿童股骨骨肉瘤保肢术中,具有操作简便、临床疗效好、术后并发症少等优点。
Objective To analyze the curative effect and application value of epiphyseal retraction and metaphysis in limb salvage in children with femoral osteosarcoma. Methods From January 2007 to January 2011, 6 children with distal femoral osteosarcoma were treated. 4 males and 2 females; aged 9 to 14 years old, with an average of 11.4 years old. Duration of 1 to 9 months, an average of 4.8 months. Preoperative biopsy by puncture or confirmed osteosarcoma, including osteogenic sarcoma in 1 case, 1 case of chondroblastic osteosarcoma, osteoblastic osteosarcoma in 1 case, no clear cell classification of osteosarcoma in 3 cases. According to Enneking proposed surgical staging system, including 1 case of Ⅱ A, Ⅱ B 5 cases. Preoperative use of neoadjuvant chemotherapy 2 cycles; first line Ca adell epiphysis distraction hysterectomy surgery, distraction time 4 ~ 7 d, an average of 5.7 d; epiphysis diverting metaphyseal surgery completed 1 ~ 2 d after bone tumor resection, Using large bone allograft reconstruction; postoperative chemotherapy and regular follow-up to understand fracture healing, lower limb development and complications such as local and systemic conditions, and according to the American Society of musculoskeletal tumors (MSTS) score system score and knee activity (Range of motion, ROM) for functional assessment. Results One case of superficial infection of the incision occurred after operation and healed after the dressing change. All the other incisions healed in the first stage. Six patients were followed up for 1-5 years, with an average of 2.5 years. No obvious symptoms such as swelling and pain were found in the limbs. No allograft rejection and loosening or rupture of the internal fixation occurred. No complications such as tumor metastasis and local recurrence were observed after operation. Metaplasia of metaphysis was healed in 6 to 9 months postoperatively in 5 cases and in 14 months in 1 case. Delayed healing took place in all the parts of the bone. At 12 to 48 months after operation, clear and distinct. At the last follow-up, the affected limbs were shortened 1 to 3 cm in 4 cases and 3 to 5 cm in 2 cases. Three patients had compensatory scoliosis and 2 had obvious lameness. MSTS score was (27.20 ± 1.92) (19.60 ± 2.74), there was significant difference between the two groups (t = -4.12, P = 0.00); ROM of ipsilateral knee joint was (127.00 ± 17.89) °, there was no significant difference compared with preoperative (109.00 ± 12.45) ° (T = -1.84, P = 0.10). There was no significant difference between ROM and healthy knee ROM (126.00 ± 9.62) ° (t = -0.11, P = 0.92). Conclusion Epiphyseal distraction epiphyseal surgery can be applied to epiphyseal not closed children femoral osteosarcoma limb salvage surgery, with simple, clinical efficacy, fewer postoperative complications.