一期胫骨近端半关节置换联合二期翻修治疗三例儿童胫骨近端骨肉瘤

2019-03-21 李远 徐海荣 单华超 中国修复重建外科杂志

男,12岁。因左胫骨近端肿痛2个月于2009年入院。入院查体:左胫骨近端前内侧肿物,质硬,不活动,有压痛,局部皮温高,膝关节活动无受限。膝关节下10CM处周径较对侧大2CM。测量双侧股骨长度(股骨头最高点至膝关节中心距离)、胫骨长度(膝关节中心至踝关节中心距离)、下肢全长(股骨头最高点至踝关节中心距离),见表1。入院后行X线片、CT、MRI检查,显示胫骨近端溶骨成骨混合性骨破坏,骨皮质破坏,可见骨

据统计,胫骨近端是骨肉瘤第二好发部位,24%经典型骨肉瘤发生于此。术前化疗-手术-术后辅助化疗是经典治疗方案,患者5年生存率可达70%。目前,胫骨近端骨肉瘤常用重建方法为人工关节置换,它可以早期提供稳定关节,术后恢复快,外观良好,患者及家属易于接受。但是对于儿童胫骨近端骨肉瘤患者,切除骨肉瘤的同时切除了胫骨近端骨骺和骺板,安装股骨侧假体时会破坏股骨侧骨骺和骺板,均会造成肢体不等长,影响术后功能恢复。因此,儿童保肢手术中重建方式的选择非常重要,是保留患肢功能和维持双侧肢体长度平衡的关键。

我们针对儿童骨肉瘤患者改良了常规人工关节置换术,设计分期治疗方案,即手术切除肿瘤后一期采用胫骨近端半关节假体置换,重建肢体外形及功能,同时避免了股骨侧假体对股骨生长发育的影响;待患儿成年后进行假体翻修术,更换全部假体或安装股骨侧假体,恢复患肢稳定性,以减少肢体不等长程度。目前,我们采用该分期治疗方案治疗了3例儿童胫骨近端骨肉瘤,现总结治疗经验,报告如下。

临床资料

一般资料   例1 男,12岁。因左胫骨近端肿痛2个月于2009年入院。入院查体:左胫骨近端前内侧肿物,质硬,不活动,有压痛,局部皮温高,膝关节活动无受限。膝关节下10CM处周径较对侧大2CM。测量双侧股骨长度(股骨头最高点至膝关节中心距离)、胫骨长度(膝关节中心至踝关节中心距离)、下肢全长(股骨头最高点至踝关节中心距离),见表1。入院后行X线片、CT、MRI检查,显示胫骨近端溶骨成骨混合性骨破坏,骨皮质破坏,可见骨膜反应及软组织肿块。全身骨扫描显示胫骨近端放射性异常浓聚,其他部位未见放射性异常浓聚。胸部CT检查未见转移。经活检后确诊为经典型骨肉瘤(ⅡB期)。术前化疗4个疗程:第1周甲氨蝶呤(MTX)10g/m2,第3周异环磷酰胺(IFO)15g/m2,第6周顺铂(DDP)80mg/m2+多柔比星(ADM)60mg/m2,第8周MTX10g/m2。入院后第10周手术。

例2 男,13岁。因左胫骨近端肿痛2个月并逐渐加重于2013年入院。入院查体:左小腿近端肿胀,皮肤颜色正常,皮温高;前侧可触及质硬肿物,边界不清,不活动,有压痛;膝关节活动无明显受限;膝关节下10CM处周径较对侧大3CM。双侧股骨长度、胫骨长度及下肢全长见表1。入院后行X线片、CT、MRI检查,显示胫骨近端成骨性破坏,可见骨膜反应及软组织肿块。全身骨扫描显示胫骨近端放射性异常浓聚,其他部位未见放射性异常浓聚。胸部CT检查未见转移。经活检后确诊为经典型骨肉瘤(ⅡB期)。术前化疗4个疗程,方案同例1。

例3 女,13岁。因左小腿近端肿痛3个月并逐渐加重于2012年入院。入院查体:左小腿近端肿胀,皮肤颜色正常,皮温高;前侧可触及质硬肿物,边界不清,不活动,有压痛;膝关节活动无明显受限;膝关节下5CM处周径较对侧大2CM。双侧股骨长度、胫骨长度及下肢全长见表1。入院后行X线片、CT、MRI检查,显示胫骨近端溶骨成骨混合性骨破坏,可见骨膜反应及软组织肿块。全身骨扫描显示胫骨近端放射性异常浓聚,其他部位未见放射性异常浓聚。胸部CT检查未见转移。经活检后确诊为经典型骨肉瘤(ⅡB期)。术前化疗4个疗程:第1周IFO15g/m2,第4周MTX10g/m2,第6周DDP80mg/m2+ADM60mg/m2,第8周MTX10g/m2;入院后第10周手术。

手术方法    一期手术 一期手术切除肿瘤并胫骨近端半关节置换;使用北京力达康科技有限公司定制型(例1)或组配式(例2、3)胫骨近端肿瘤假体;例1、2定制胫骨假体近端垫片,在垫片中部前后排列2~3对重建孔用于重建交叉韧带附丽;例3使用常规假体垫片。根据化疗后影像学检查结果确定手术方案,距离影像学肿瘤边缘2~5CM作为胫骨截骨平面。作胫骨近端前侧纵切口,切口近端弧形绕过髌骨外缘。遵循无瘤原则,将活检道与肿瘤完整切除。髌腱距离止点1CM切断;腓骨近端和肿瘤一同切除;近端切除半月板;交叉韧带距离胫骨侧止点1CM切断。切除肿瘤后,远端胫骨扩髓。从胫骨侧垫片底面一侧重建孔穿入2~3条5号爱惜邦EXCELMB66线,与残留的交叉韧带缝合,在垫片底打结将垫片固定于股骨远端,重建交叉韧带。取双层聚丙烯人工补片,用2号爱惜邦EXCELX519线缝合在残留关节囊和侧副韧带上备用。安装胫骨近端假体,用骨水泥固定。根据局部软组织情况,假体长度可比切除长度长1.0~1.5CM。于屈膝90°位将胫骨假体垫片安装到假体上。膝关节置于伸直位,用人工补片紧紧包绕假体,利用假体近端预留固定髌韧带的预留孔缝合固定补片,使补片与假体成为一体。将髌腱缝合固定在胫骨前侧补片上。腓肠肌内侧头转移覆盖假体前方。关闭切口。

术后持续引流,待引流量<50mL/d后拔除引流管。术后2周切口拆线。例1术后化疗15疗程,例2、3术后化疗12疗程,仍为MTX、IFO、DDP、ADM四药交替使用,剂量与术前化疗相同。术后长腿石膏后托将患肢固定于膝关节伸直位8~12周,期间行患肢肌肉等长收缩及直腿抬高锻炼;去除石膏后开始膝关节屈伸功能锻炼,并扶拐下地活动,之后逐渐弃拐行走。

二期手术 例1患者20岁以及例2、3患者17岁时行二期假体翻修术。例1患者因一期手术时使用的假体型号停产,无合适组件翻修,故选择将胫骨侧假体取出,整体更换为美国史赛克公司GMRS通用组配式假体。例2、3患者术中仅安装股骨侧假体组件、更换胫骨侧垫片。沿膝关节原手术切口切开,显露股骨远端和假体近端。股骨截骨安装假体,骨水泥固定。取出胫骨侧临时垫片,更换普通垫片。植入膝关节旋转连接组件(高10mm),复位后放置引流管,关闭切口。术后持续引流,待引流量<50mL/d后拔除引流管。术后1周可下地锻炼行走。

结果

本组3例均顺利完成两期手术,术后切口均愈合良好,无手术相关并发症发生;随访期间均无肿瘤复发转移。两期手术前后测量下肢全长及胫骨、股骨长度见表1。其中,例1患者一期术后7d、二期术后9d,例2患者一期术后14d、二期术后6d,例3患者一期术后15d、二期术后2d进行测量。并计算同时间点健患侧肢体差值以及同一肢体手术前后差值。

例1一期术后随访8年,患者行走无疼痛,但长距离行走后存在膝关节不适,休息后好转,无需支具辅助,美国骨与软组织肿瘤协会功能评分标准(MSTS)评分为24分;X线片显示半关节假体位置良好。二期术后随访13个月,MSTS评分26分。见图1。



例2一期术后随访4年,患者行走无疼痛,但长距离行走后存在膝关节不适,休息后好转,无需支具辅助,MSTS评分为24分;X线片显示半关节假体位置良好。二期术后随访3个月,MSTS评分27分。见图2。



例3一期术后随访3年,行走无疼痛,日常使用单侧手杖辅助行走,负重时患侧膝关节轻度内翻,长距离行走后膝关节不适,休息后好转,MSTS评分20分;X线片显示胫骨侧假体轻度外移。二期术后随访27个月,MSTS评分25分。见图3。



讨论

儿童胫骨近端骨肉瘤保肢治疗后均存在肢体不等长问题。为解决人工关节置换术后患肢不等长问题,有医生使用可延长假体补偿肢体长度差异。但是因可延长假体设计及使用复杂,与成人患者使用肿瘤型假体相比,其并发症发生率高,假体生存率低。有报道采用骨搬运技术解决儿童人工关节置换术后肢体不等长问题,即在儿童期行人工关节置换治疗胫骨近端骨肉瘤,待成年后在股骨干运用骨搬运技术行肢体延长术。该方法虽能有效恢复肢体长度,但需要长期使用外固定架,对于体内有人工假体的患者有巨大潜在感染风险,而且肢体延长术本身也存在较多并发症。

对于胫骨近端骨肉瘤切除后采用人工关节置换重建的患儿,术后肢体短缩不仅与切除胫骨近端生长板有关,术中安装股骨侧假体破坏股骨侧生长板,也会造成肢体长度损失以及患侧膝关节平面上移,甚至后者造成的肢体不等长超过前者。本组3例患者二期术前测量双下肢全长相差平均34mm,其中双侧股骨长度仅相差约10mm,提示保护股骨远端生长板,对减轻肢体不等长有重要作用。因此,我们在原人工关节置换术重建基础上,提出了改良的两期手术,主要包括:①一期常规切除肿瘤,使用胫骨近端半关节假体置换,不安装股骨侧假体组件,保留股骨远端生长板完整性,保留患儿股骨远端的生长能力;②采用改良标准胫骨近端假体垫片重建交叉韧带,维持临时假体稳定性;③使用人工补片重建内外侧副韧带及髌腱,维持临时假体稳定及膝关节运动功能;④使用标准组配假体柄及体,以利于二期翻修;⑤待患儿成年后进行假体翻修,安装股骨侧假体组件,恢复膝关节稳定性。本组患者通过二期手术后双下肢长度平均相差约16mm,患者术后功能满意。

青春期是骨骼发育成熟前最后一个生长高峰,在此期间下肢生长速度从3.2CM/年增加到5CM/年,男孩下肢长度增长每年可达10CM、女孩为9CM,其中股骨远端占股骨生长的70%,胫骨近端占胫骨生长的57%。下肢生长峰值约出现在男孩骨龄14岁和女孩骨龄12岁,这个生长高峰可以持续3年。

Li等报道年龄超过16岁且经过化疗的骨肉瘤患者下肢长度基本不增长。而对于生长板破坏后造成的肢体生长停滞程度可以预估。根据Pritchett及Li等的计算方法,如12岁男孩,股骨长度400mm,如此时股骨远端损伤导致生长板破坏生长停滞,最终造成双下肢长度差值为35mm。

因此,对于处于生长高峰结束前的患者(男孩未满15岁、女孩未满13岁),可选择一期胫骨近端半关节置换治疗,待17岁后行二期翻修手术。但是值得注意的是,两期手术虽然避免了股骨远端骨骺破坏造成的肢体不等长,但无法解决胫骨近端切除造成的肢体不等长,而且年龄越小,肢体长度差异越大,对于未满12岁男孩和未满10岁女孩,即使通过此手术,最终肢体长度差也将超过30mm,需要结合肢体延长术才能维持肢体等长。

胫骨近端半关节置换可以减轻双下肢不等长的程度,但因其与股骨侧无金属机械连接,术后极易出现关节不稳定、疼痛、畸形,甚至脱位。为解决此问题,我们在一期手术时特别定制胫骨平台垫片,在垫片中心预留2~3对固定孔,术中用爱惜邦不可吸收线重建交叉韧带,维持膝关节前后稳定性;再用双层人工补片缝合于残留关节囊和内外侧副韧带上,重建侧方稳定。在重建膝关节稳定性的同时将髌腱用爱惜邦不可吸收线缝合固定在人工补片表面,重建伸膝功能。经过上述方法重建,患者在二期手术前可以不使用支具独立行走。

本组例1患者二期翻修时因同型号假体停产,无配套组件,只能将原假体取出,整体更换。另外两例患者选用组配式肿瘤型假体,在翻修时仅需安装股骨侧假体组件,更换标准胫骨平台垫片,如果术中假体长度需要调整,还可通过更换假体延长组件完成,不必取出骨水泥固定的假体柄,这样显著减少了手术创伤,有利于患者术后康复。因此,我们建议对于拟行两期手术的患者,在一期手术时宜选用产品成熟的组配式肿瘤型假体,避免二期整体更换假体。

另外,应注意本组采用的治疗方案需要患者和家属具有良好的依从性。他们需要意识到分期手术的必要性,包括即使在没有假体松动情况下,也需要进行一次翻修手术。患者和家属需要理解潜在的并发症风险,如感染、膝关节不稳定、部件松动、假体周围骨折等。

综上述,一期切除肿瘤后使用胫骨近端半关节假体置换,不安装股骨侧假体组件,保留了股骨远端生长板完整性,保留了股骨远端生长能力,降低了双下肢不等长程度。待患者成年后再行二期假体翻修,安装股骨侧假体组件,恢复膝关节稳定性。剩余的胫骨近端切除造成的肢体不等长,可以通过穿戴矫正鞋弥补。另外术中有意识增加假体长度,也可以进一步减少双下肢不等长程度。但是我们仅临床应用治疗3例患者,该治疗方案的疗效、并发症和注意事项等均有待扩大样本量进一步研究明确。

原始出处:

李远;徐海荣;单华超;等;一期胫骨近端半关节置换联合二期翻修治疗三例儿童胫骨近端骨肉瘤;《中国修复重建外科杂志》2019年第02期

版权声明:
本网站所有内容来源注明为“梅斯医学”或“MedSci原创”的文字、图片和音视频资料,版权均属于梅斯医学所有。非经授权,任何媒体、网站或个人不得转载,授权转载时须注明来源为“梅斯医学”。其它来源的文章系转载文章,或“梅斯号”自媒体发布的文章,仅系出于传递更多信息之目的,本站仅负责审核内容合规,其内容不代表本站立场,本站不负责内容的准确性和版权。如果存在侵权、或不希望被转载的媒体或个人可与我们联系,我们将立即进行删除处理。
在此留言
评论区 (6)
#插入话题
  1. [GetPortalCommentsPageByObjectIdResponse(id=370401, encodeId=c3543e040110, content=胫骨近端半关节置换术。, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Sun Jul 28 12:03:20 CST 2019, time=2019-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742590, encodeId=ae3e1e4259070, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Sat Oct 19 09:41:00 CST 2019, time=2019-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364115, encodeId=c75436411574, content=胫骨近端半关节置换。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Apr 04 19:56:36 CST 2019, time=2019-04-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363527, encodeId=9e2036352e56, content=骨端半关节置换联合。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Mar 25 18:07:14 CST 2019, time=2019-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412170, encodeId=0ed214121e049, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579507, encodeId=cdac15e95072e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=)]
    2019-07-28 jyzxjiangqin

    胫骨近端半关节置换术。

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=370401, encodeId=c3543e040110, content=胫骨近端半关节置换术。, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Sun Jul 28 12:03:20 CST 2019, time=2019-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742590, encodeId=ae3e1e4259070, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Sat Oct 19 09:41:00 CST 2019, time=2019-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364115, encodeId=c75436411574, content=胫骨近端半关节置换。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Apr 04 19:56:36 CST 2019, time=2019-04-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363527, encodeId=9e2036352e56, content=骨端半关节置换联合。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Mar 25 18:07:14 CST 2019, time=2019-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412170, encodeId=0ed214121e049, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579507, encodeId=cdac15e95072e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=)]
    2019-10-19 yxch48
  3. [GetPortalCommentsPageByObjectIdResponse(id=370401, encodeId=c3543e040110, content=胫骨近端半关节置换术。, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Sun Jul 28 12:03:20 CST 2019, time=2019-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742590, encodeId=ae3e1e4259070, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Sat Oct 19 09:41:00 CST 2019, time=2019-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364115, encodeId=c75436411574, content=胫骨近端半关节置换。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Apr 04 19:56:36 CST 2019, time=2019-04-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363527, encodeId=9e2036352e56, content=骨端半关节置换联合。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Mar 25 18:07:14 CST 2019, time=2019-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412170, encodeId=0ed214121e049, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579507, encodeId=cdac15e95072e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=)]
    2019-04-04 jyzxjiangqin

    胫骨近端半关节置换。

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=370401, encodeId=c3543e040110, content=胫骨近端半关节置换术。, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Sun Jul 28 12:03:20 CST 2019, time=2019-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742590, encodeId=ae3e1e4259070, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Sat Oct 19 09:41:00 CST 2019, time=2019-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364115, encodeId=c75436411574, content=胫骨近端半关节置换。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Apr 04 19:56:36 CST 2019, time=2019-04-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363527, encodeId=9e2036352e56, content=骨端半关节置换联合。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Mar 25 18:07:14 CST 2019, time=2019-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412170, encodeId=0ed214121e049, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579507, encodeId=cdac15e95072e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=)]
    2019-03-25 jyzxjiangqin

    骨端半关节置换联合。

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=370401, encodeId=c3543e040110, content=胫骨近端半关节置换术。, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Sun Jul 28 12:03:20 CST 2019, time=2019-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742590, encodeId=ae3e1e4259070, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Sat Oct 19 09:41:00 CST 2019, time=2019-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364115, encodeId=c75436411574, content=胫骨近端半关节置换。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Apr 04 19:56:36 CST 2019, time=2019-04-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363527, encodeId=9e2036352e56, content=骨端半关节置换联合。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Mar 25 18:07:14 CST 2019, time=2019-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412170, encodeId=0ed214121e049, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579507, encodeId=cdac15e95072e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=)]
    2019-03-23 yb6561
  6. [GetPortalCommentsPageByObjectIdResponse(id=370401, encodeId=c3543e040110, content=胫骨近端半关节置换术。, beContent=null, objectType=article, channel=null, level=null, likeNumber=75, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Sun Jul 28 12:03:20 CST 2019, time=2019-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742590, encodeId=ae3e1e4259070, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Sat Oct 19 09:41:00 CST 2019, time=2019-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=364115, encodeId=c75436411574, content=胫骨近端半关节置换。, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Thu Apr 04 19:56:36 CST 2019, time=2019-04-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=363527, encodeId=9e2036352e56, content=骨端半关节置换联合。, beContent=null, objectType=article, channel=null, level=null, likeNumber=97, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Mar 25 18:07:14 CST 2019, time=2019-03-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1412170, encodeId=0ed214121e049, content=<a href='/topic/show?id=504a83820a0' target=_blank style='color:#2F92EE;'>#胫骨#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83820, encryptionId=504a83820a0, topicName=胫骨)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5c442828835, createdName=yb6561, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1579507, encodeId=cdac15e95072e, content=<a href='/topic/show?id=3afd942e905' target=_blank style='color:#2F92EE;'>#近端#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=94279, encryptionId=3afd942e905, topicName=近端)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=da2116536440, createdName=hittouch, createdTime=Sat Mar 23 09:41:00 CST 2019, time=2019-03-23, status=1, ipAttribution=)]
    2019-03-23 hittouch

相关资讯

JAHA:什么?骨中的铅含量还与顽固性高血压有关?

密歇根大学公共卫生学院流行病学和环境健康科学系学者在《美国心脏协会杂志》发表的一项研究提示,胫骨中铅含量的积累与顽固性高血压有关。

胫骨外侧锁定板结合空心钉治疗Hoffa骨折2例

Hoffa骨折是指股骨远端冠状位骨折,包括单髁或双髁,属于关节内的骨折,存在很大的剪切力。无论移位与否,都主张手术治疗,要求解剖复位、坚强内固定、早期功能锻炼。从以往的文献报道及临床实践中得知,保守治疗存在再移位的风险。目前对于内固定的选择较多,包括髁部钢板、“T”板及重建板等,但仍有不足。笔者在临床工作中发现,灵活运用同侧胫骨远端外侧锁定钢板结合空心螺钉治疗外侧Hoffa骨折LetenneurI

双侧胫骨骨内腱鞘囊肿1例

骨内腱鞘囊肿是骨的良性病变,临床上多为单发,多发病例少见,临床表现为病变部位的慢性疼痛,缺乏特异性,为进一步加强对本病的认识,本文对我院收治的1例患者进行报道并文献复习。

胫骨近端骨纤维结构不良骨肉瘤变一例

骨纤维结构不良(FD)又被称为纤维异常增生症,为一种较常见的骨瘤样病变,主要表现为受累骨组织内有纤维组织增生,并有不同程度的骨化生,X线表现为“磨砂玻璃样改变”。其临床表现可以分为单骨型、多骨型和ALbringt综合征。骨纤维结构不良极少恶变。即使恶变多因手术或者局部慢性炎症刺激等造成。但是,我院近期收治一例胫骨近端骨纤维结构不良骨肉瘤变患者,该患者既往未曾手术,且局部亦无慢性炎症,现报道如下:

胫骨新型隐球菌性骨髓炎1例

患者,男,73岁,因右踝肿痛20d入院。20d前无明显诱因出现右踝肿痛,疼痛持续,右踝活动受限。既往房性早搏10年,无饲养宠物史。查体:右踝肿胀,局部压痛,皮肤发红不明显,皮温略升高,浅表静脉无怒张,关节活动受限。

胫骨衰竭骨折延误诊治2例

衰竭骨折是应力骨折的一种,属于隐匿性骨折,在正常重复应力刺激下发生,且常发生于异常骨质,容易被忽视而漏诊。笔者收集2例延误诊治的胫骨衰竭骨折患者的临床资料,报道如下。