O'Connor M I, Sim F H, Chao E Y
Department of Orthopedic Surgery, Mayo Clinic Jacksonville, Florida 32224, USA.
J Bone Joint Surg Am. 1996 Dec;78(12):1872-88. doi: 10.2106/00004623-199612000-00011.
The intermediate functional results were assessed for fifty-seven patients who had had a limb-salvage procedure for treatment of a tumor of the shoulder girdle region at our institution from 1980 through 1990. Fifty-three patients had a malignant bone tumor (a sarcoma) and four had an extensive giant-cell tumor. The resections were classified according to the system of the Musculoskeletal Tumor Society. A variety of reconstructive procedures were performed after resection of the tumor, with the choice of procedure depending on the type of resection and the needs of the patient. The functional results were described and graded quantitatively according to the functional rating system of the Musculoskeletal Tumor Society. The average duration of follow-up was 5.3 years (median, 4.6 years) for the forty-seven patients who were still alive at the time of the latest follow-up examination. Eight patients died of disease and two others died of unrelated malignant tumors an average of 1.8 years postoperatively. The resection of the tumor was classified as wide in forty of the fifty-three patients who had a sarcoma and as marginal in thirteen; four patients had local recurrence (two, after a wide resection, and two, after a marginal resection). One of the four patients who had a giant-cell tumor had local recurrence. The functional results were related to the type of resection and the method of skeletal reconstruction. After resection of the entire scapula and the proximal aspect of the humerus, reconstruction with a spacer frequently resulted in asymptomatic superior subluxation of the implant and poor function of the shoulder. After extra-articular resection of the glenoid cavity and the proximal aspect of the humerus with loss of the abductor mechanism, osseous arthrodesis resulted in good function that was superior to that found after reconstruction with a spacer or a proximal humeral replacement prosthesis. Our preferred method to achieve fusion was insertion of an intercalary allograft and a vascularized fibular graft. However, the allograft fractured in three of four patients in whom primary fusion had been obtained with this technique. An osteoarticular allograft inserted after intra-articular resection of the proximal aspect of the humerus and preservation of the abductor mechanism provided good function that was superior to that found after reconstruction with a proximal humeral replacement prosthesis, which produced symptomatic instability that led to a secondary arthrodesis in some patients. However, subchondral fracture and collapse of the osteoarticular allograft occurred in four of eight patients by the time of the latest follow-up examination. The results of all methods of reconstruction were satisfactory with regard to pain, emotional acceptance, and manual dexterity. We believe that the use of a method of reconstruction that is appropriate with regard to the needs of the patient and preoperative counseling regarding the expected functional level and restrictions of activity are critical for a high level of postoperative satisfaction.
对1980年至1990年间在本机构接受保肢手术治疗肩胛带区域肿瘤的57例患者的中期功能结果进行了评估。53例患者患有恶性骨肿瘤（肉瘤），4例患有广泛性巨细胞瘤。根据肌肉骨骼肿瘤学会的系统对切除术进行分类。肿瘤切除后进行了各种重建手术，手术方式的选择取决于切除类型和患者需求。根据肌肉骨骼肿瘤学会的功能评分系统对功能结果进行定量描述和分级。在最近一次随访检查时仍存活的47例患者的平均随访时间为5.3年（中位数为4.6年）。8例患者死于疾病，另外2例死于无关的恶性肿瘤，平均术后1.8年。在53例患有肉瘤的患者中，40例的肿瘤切除被分类为广泛切除，13例为边缘切除；4例患者出现局部复发（2例在广泛切除后，2例在边缘切除后）。4例患有巨细胞瘤的患者中有1例出现局部复发。功能结果与切除类型和骨骼重建方法有关。切除整个肩胛骨和肱骨近端后，使用间隔物重建常常导致植入物无症状性上半脱位和肩部功能不佳。在关节外切除关节盂和肱骨近端且外展机制丧失后，骨融合术产生的功能良好，优于使用间隔物或肱骨近端置换假体重建后的功能。我们实现融合的首选方法是插入节段性同种异体骨和带血管的腓骨移植。然而，在使用该技术实现初次融合的4例患者中，有3例同种异体骨发生骨折。在肱骨近端关节内切除并保留外展机制后插入骨-关节同种异体骨，其功能良好，优于使用肱骨近端置换假体重建后的功能，后者会产生有症状的不稳定，导致一些患者进行二次融合术。然而，到最近一次随访检查时，8例患者中有4例发生了骨-关节同种异体骨的软骨下骨折和塌陷。所有重建方法在疼痛、情感接受度和手部灵活性方面的结果都令人满意。我们认为，根据患者需求选择合适的重建方法以及就预期功能水平和活动限制进行术前咨询对于提高术后满意度至关重要。
