目的 通过分析原发性恶性骨肿瘤患者在瘤段切除后经不同重建方式治疗的随访资料,探讨手术方案的选择对临床疗效的影响.方法 以2016年7月1日至2022年7月1日东部战区总医院单中心收治的四肢原发性恶性骨肿瘤患者为研究对象,根据瘤段切除后重建方式分为肿瘤型假体置换组和生物重建组.回顾患者的临床随访资料,对比2组患者至随访截止时间的复发率、转移率、生存率以及最终保肢率,并总结生物重建失败的影响因素.同时,采用美国肌肉骨骼肿瘤协会评分(MSTS)、多伦多保肢评分(TESS)评价并比较不同组间患者术后功能的恢复情况.结果 共收集并筛选入组患者87例,其中男52例,女35例,年龄8～71岁,平均(38.3±21.2)岁.随访15～70个月,平均随访时间26.5个月.至随访截止时间,共存活67例,死亡20例,总生存率为77.01%;无瘤存活45例,无瘤生存率为51.72%.其中,假体置换组74例、生物重建组13例(瘤体骨灭活再植钢板重建2例、自体腓骨移植钢板重建11例).生物重建组术后1年的MSTS评分及TESS评分均明显高于假体置换组(28.33±2.09 vs 24.16±4.51、85.62±6.71 vs 80.82±3.85,P<0.01).假体置换组术后生存率达到了75.68%.而生物重建组患者术后生存率更达到了84.62%,且根据多因素Cox比例风险回归分析结果,不同的手术方式对无瘤生存(TFS)、总生存(OS)均无显著影响(P>0.05),复发和转移发生与否才是影响OS的预测因素(P=0.003和P=0.001).而进一步的研究显示,两种不同手术方式的选择与患者的生存率(P=0.0843)、复发率(P=0.5206)、转移率(P=0.3217)无显著相关性.假体置换组与生物重建组的二次手术率(29.73%vs 38.46%)及最终保肢率(83.78%vs 84.62%)比较,差异均无统计学意义(P>0.05).行瘤段切除后自体腓骨移植钢板重建的患者有11例,其中出现移植骨骨不连2例;愈合时间与年龄、术前肿瘤生长部位、术中截骨长度、取骨部位及植骨量均有相关性(P<0.05).结论 随着治疗理念和手术技术的不断进步,针对原发性恶性骨肿瘤瘤段切除后的骨缺损,采用术前精准测量和周密设计的生物重建手术,可以发挥其在关节稳定、肢体功能、保障疗效等各方面的优势,从而取得较假体置换手术更佳的治疗效果.
Follow up study of different reconstruction methods for the treatment of primary malignant bone tumors in the limbs
Objective By analyzing the follow-up materials of different reconstruction methods after resection of primary malig-nant bone tumor,this study was aimed to investigate the effect of surgi-cal choices on the clinical efficacy.Methods The patients with ex-tremities primary malignant bone tumors in single center of General Hospital of Eastern Theater Command from July 1,2016 to July 1,2022 were taken as the research objects and divided into tumor type prosthesis replacement group and biological reconstruction group.The clinical follow-up data of the patients were reviewed.We analyzed the recurrence rate,metastasis rate,survival rate and ultimate limb salvage rate of each group,and summarized the influencing factors of bi-ological reconstruction failure.The postoperative functional recovery of in different groups were compared and evaluated by the muscu-loskeletal tumor score(MSTS)and the Toronto extremity salvage score(TESS).Results 87 patients were collected and screened in this study,including 52 males and 35 females,aged from 8 to 71 years,with an average age of 38.3±21.2 years.The patients were fol-lowed up for 15 to 70 months,with an average follow-up time of 26.5 months.By the end of follow-up,67 patients survived and 20 died,with a total survival rate of 77.01%.Tumor free survival rate was 51.72%.Including 74 cases of prosthesis replacement and 13 cases of biological reconstruction after tumor segment resection(2 cases of reconstruction by tumor bone inactivated replantation and 11 cases of reconstruction by autogenous fibular).The MSTS score and TESS score in the biological reconstruction group were significantly high-er than those in the prosthesis replacement group one year after operation(28.33±2.09 vs 24.16±4.51,85.62±6.71 vs 80.82±3.85,P<0.01).The survival rate after prosthesis replacement was 75.68%,and the survival rate of patients with biological reconstruction was 84.62%.According to the results of multivariate Cox proportional hazard regression analysis,different surgical methods had no signifi-cant impact on TFS and OS(P>0.05).Moreover,recurrence and metastasis were predictors of OS(P=0.003 and P=0.001).Further studies showed that the different surgical methods were not significantly related to the survival rate(P=0.0843),recurrence rate(P=0.5206),and metastasis rate(P=0.3217)of patients.There was no statistically significant difference in the secondary surgery rate(29.73%vs 38.46%)and the ultimate limb salvage rate(83.78%vs 84.62%)between tumor type prosthesis replacement group and bi-ological reconstruction group(P>0.05).In this study,there were 11 patients of reconstruction by autogenous fibular,of which 2 cases with bone nonunion.The healing time was correlated with age,preoperative tumor growth site,intraoperative osteotomy length,bone ex-traction site and bone graft volume(P<0.05).Conclusion With the continuous advancement of treatment concept and surgical technology,the use of the biological reconstruction surgery,which has been accurately measured and carefully designed before surgery for the reconstruction of bone defects after tumor segments resection of primary malignant bone tumors,can leverage its advantages in advantages in joint stability,limb function,and efficacy assurance,thereby achieving better therapeutic effect than the prosthesis re-placement surgery.
primary malignant bone tumordifferent reconstruction methods after resectionfunctional evaluationsurvival and limb salvagerecurrence and metastasisfollow-up study
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