同种异体骨单髁置换治疗膝关节周围骨肿瘤的长期评价

发布时间：2018-01-02 16:13

本文关键词：同种异体骨单髁置换治疗膝关节周围骨肿瘤的长期评价　出处：《山东大学》2015年硕士论文　论文类型：学位论文

【摘要】：膝关节主要由股骨下端、胫骨上端及髌骨组成,其中前两者为骨肿瘤好发部位,例如良性的具有侵袭特性的骨巨细胞瘤,恶性的骨肉瘤、恶性纤维组织细胞瘤等。手术治疗是现阶段的主要治疗措施,但其会造成切除部位骨质缺损,从而影响膝关节相应功能。对于仅发生在内髁或外髁处的肿瘤,由于其切除后会严重影响膝关节的功能及稳定性,因此关节重建势在必行。现阶段主要手术方式包括异体骨移植(包括单髁和半关节移植),自体骨移植,人工关节置换重建,异体骨+人工关节复合移植。其中人工关节置换重建具有即刻稳定,早期活动等优点,但具有手术创伤较大,生物力学改变,后期翻修、感染、松动等缺陷；半关节移植虽可保留相应韧带软骨,维持关节稳定,但却牺牲了对侧无肿瘤侵袭的健康单髁,增加了后期关节磨损的风险；而自体骨移植虽无排异反应,但却明显影响关节的功能。而同种异体骨单髁置换,既保留了骨量,不影响对侧半关节,极大程度的保留原膝关节原有功能,后期如有必要仍可行人工关节重建。因此,对发生于膝关节周围局限于单髁的肿瘤,特别是像骨巨细胞瘤一类的良性侵袭性肿瘤,同种异体骨单髁置换可能为更加合理的选择。目的：探讨同种异体骨单髁置换,对发生于股骨下段或胫骨上段,局限于单髁的骨肿瘤的术后功能及影像学评价。总结手术后常见并发症及相应注意事项。方法：选自1991.1至2014.10期间,我院收治的发生于股骨下段及胫骨上段单侧髁的骨肿瘤11例,术前影像学检查确认,肿瘤侵及范围未超过髁部横断面的1/2,未突破关节面,未侵犯血管神经束,局部软组织情况良好。男8例,女3例。其中骨巨细胞瘤8例,恶性纤维组织细胞瘤2例,良性纤维组织细胞瘤1例。其中骨巨细胞瘤Campanacci分级Ⅱ级6例,Ⅲ级2例,恶性骨肿瘤均为IIA期。股骨外侧髁7例,股骨内侧髁2例,胫骨内侧髁2例。手术时平均年龄35.3岁(22～46岁),1例骨巨细胞瘤为刮除植骨复发再次手术,其余10例均为初次手术。所有患者术前均经X线、CT及MRI确定病变范围及术中切除瘤段骨范围,术前准备体积形态合适同种异体骨单髁备用。对于良性肿瘤行边缘切除,恶性肿瘤行广泛切除。应用Musculoskeletal Tumor Society (MSTS)下肢功能评分系统及the International Society of Limb Salvage (ISOLS)影像学评分系统,对患者术后下肢功能及移植骨影像学评分,系统的评价同种异体骨单髁置换的预后长期评价。结果：所有11例手术均按照预期完成。术后随访平均时间148.6月(9～288月)。患者1例恶性纤维组织细胞瘤患者,术后5年因肺转移去世；1例骨巨细胞瘤患者,术后2年局部复发,行膝关节假体置换,术后无瘤生存；其余9例患者均长期无瘤生存。现继续使用异体骨单髁置换9名。其中1例因螺钉断裂取出,1例主动要求钢板取出。4例患者出现较明显的关节退变表现,1例出现骨不连,6例出现骨质吸收。MSTS下肢功能评分为25.6分(17～30分),ISOLS影像学评分为85.5%(69.4%～97.2%)。结论：对于膝关节周围局限于单髁的肿瘤而言,面对肿瘤切除后的骨缺损,行同种异体骨单髁置换术,可较好的维持膝关节原有功能,降低复发率,保持骨的生物学完整性,是一种切实可靠的手术方法。
[Abstract]:The knee joint is mainly composed of femur, tibia and patella, the former two bone tumor sites such as benign invasive characteristics of giant cell tumor, malignant osteosarcoma, malignant fibrous histiocytoma. Surgical treatment is the main treatment measures at this stage of the application, but it will cause the resection of bone defect. Which affect the knee joint function. The corresponding only, condylar or lateral condyle tumor because of its resection will seriously affect the stability and function of the knee joint, the joint reconstruction is imperative. The main operation modes of this stage include bone allograft (including single condyle and osteoarticular allograft), autogenous bone graft, artificial joint replacement reconstruction of bone allograft and artificial joint graft. The artificial joint replacement reconstruction has the advantages of immediate stability, early activity, but has a larger surgical trauma, the change of biological resources, late revision , infection, loosening and other defects; semi joint transfer can retain the corresponding ligament cartilage, maintaining joint stability, but at the expense of the non tumor invasion of the contralateral healthy unicompartment, increased the risk of late joint wear; and autogenous bone graft without rejection, but the joint function has significant effect. The allograft bone unicompartment arthroplasty, retain bone mass, does not affect the contralateral half joint, knee joint greatly to retain the original original function, later if necessary is feasible for artificial joint reconstruction. Therefore, occurs around the knee confined to single condyle tumor, especially as benign tumor invasion of giant cell tumor of bone of a class, allograft bone unicompartment arthroplasty may be more reasonable choice. Objective: To investigate the effect of allogeneic bone unicompartment arthroplasty, to occur in the distal femur or proximal tibia, bone tumor confined to single condyle postoperative function and imaging evaluation. Summarize the hand The common complications and corresponding precautions after operation. Methods: from 1991.1 to 2014.10 during the occurrence of bone tumor in our hospital in the distal femur and proximal tibia unilateral condyle in 11 cases, preoperative imaging examination confirmed that tumor invasion and the range does not exceed the condylar cross-sectional 1/2, without breaking the articular surface, without vascular invasion the nerve bundle, local soft tissue condition. 8 cases were male, 3 were female. Of which 8 cases of giant cell tumor of bone, 2 cases of malignant fibrous histiocytoma, 1 cases of benign fibrous histiocytoma. Of which 6 cases of giant cell tumor of bone Campanacci grade II, 2 cases of grade III malignant bone tumor were IIA period. The lateral femoral condyle in 7 cases, 2 cases of medial condyle of femur, 2 cases of medial condyle of tibia. The operation with an average age of 35.3 years (22 ~ 46), 1 cases of giant cell tumor of bone for curettage and bone grafting surgery recurrence, the remaining 10 cases were primary surgery. All patients underwent X-ray, CT and MRI to determine the disease the scope and operation Resection of tumor segment bone, preoperative preparation form suitable volume of allogeneic bone unicompartment for standby. Benign tumors resection margins and malignant tumor resection. The application of Musculoskeletal Tumor Society (MSTS) of lower extremity function score system and the International Society of Limb Salvage (ISOLS) imaging scoring system for postoperative lower limb function and the bone imaging score, prognosis evaluation of allogenic bone unicompartment arthroplasty system long-term evaluation. Results: all 11 cases were expected to be completed in accordance with the time. The average postoperative follow-up period was 148.6 months (9 to 288 months). 1 patients with malignant fibrous histiocytoma, 5 years after surgery for lung metastasis died; 1 cases of giant cell tumor of bone in patients with local recurrence 2 years after surgery, knee joint prosthesis replacement, disease-free survival after surgery; the remaining 9 patients had long-term disease-free survival. We continue to use allogeneic bone unicompartmental replacement 9. 1 cases were removed by screw fracture, 1 cases of active.4 patients had required the removal of steel plate joint degeneration is more obvious, 1 cases of nonunion, 6 cases of lower limb bone resorption function.MSTS score was 25.6 points (17 to 30), ISOLS imaging score was 85.5% (69.4% ~ 97.2%) on. For around the knee confined to single condyle tumor, with bone defect after tumor resection, underwent allogeneic bone unicompartmental arthroplasty, can better maintain the original function of the knee joint, reduce the recurrence rate, keep the integrity of bone biology, is a practical and reliable operation.

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R738.1

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