張遠(yuǎn)鑒 尹同珍 張文路

髖關(guān)節(jié)內(nèi)骨軟骨瘤一例報(bào)告

張遠(yuǎn)鑒 尹同珍 張文路

髖關(guān)節(jié)； 骨軟骨瘤；骨腫瘤

骨軟骨瘤是一種常見的原發(fā)性良性骨腫瘤，多見于兒童和青少年，常見累及的部位是股骨遠(yuǎn)端、橈骨近端、脛骨近端、腓骨近端、腓脛骨遠(yuǎn)端的干骺端，由于肌肉的牽拉，多背向關(guān)節(jié)生長，巨大骨軟骨瘤非常少見，位于關(guān)節(jié)內(nèi)的腫瘤更是罕見報(bào)道。

臨床資料

患者，女，48 歲，左髖部疼痛、活動(dòng)受限 10 年，加重 2 個(gè)月，2016 年 1 月 21 日入院?；颊?10 年前出現(xiàn)左髖部疼痛，勞累后加重，休息后緩解，未予特殊處理，2 個(gè)月前左髖關(guān)節(jié)疼痛加重，下蹲困難，不能盤腿，體力勞動(dòng)后明顯。查體：雙髖關(guān)節(jié)未見明顯畸形，未觸及明顯腫物，左髖關(guān)節(jié)屈曲活動(dòng)正常，外展外旋活動(dòng)明顯受限，感覺、肌力及肌張力正常。X 線片 ( 圖 1 ) 示：左髖關(guān)節(jié)處可見團(tuán)塊狀高密度影，密度不均勻。CT ( 圖 2 ) 示：左側(cè)髖臼后柱旁見團(tuán)塊狀高密度影，密度不均勻，邊界尚清，最大截面積約為 3.0 cm×4.1 cm，左髖關(guān)節(jié)滑膜增厚，左髖關(guān)節(jié)內(nèi)見液體密度影，病變與左髖臼后柱相連，雙髖關(guān)節(jié)間隙等寬，雙側(cè)股骨頭大小、形態(tài)正常，邊緣光整。MRI ( 圖 3 ) 示：雙髖關(guān)節(jié)對(duì)稱，間隙等寬，雙側(cè)股骨頭大小、形態(tài)及信號(hào)正常，邊緣光整，雙側(cè)髖臼關(guān)節(jié)面光滑清楚。雙髖關(guān)節(jié)腔見少量長 T1長 T2信號(hào)，左髖關(guān)節(jié)滑囊內(nèi)可見多個(gè)長 T1短 T2信號(hào)影，左側(cè)滑膜明顯增厚，雙髖周圍軟組織未見明顯異常信號(hào)影。初步診斷：左髖臼后壁腫瘤，骨軟骨瘤可能性大。

圖1 術(shù)前 X 線片；左髖關(guān)節(jié)處可見團(tuán)塊狀高密度影，密度不均勻Fig.1 Preoperative X-ray film：The left hip joint showed mass like high density shadow, and the density was not uniform

入院后積極術(shù)前準(zhǔn)備，完善術(shù)前相關(guān)化驗(yàn)檢查，未見明顯手術(shù)禁忌，在全麻下行左髖臼后壁腫瘤切除術(shù)。全麻滿意后，取右側(cè)臥位，常規(guī)術(shù)區(qū)消毒，取左髖關(guān)節(jié)后外側(cè)切口，長約 16 cm，依次切開皮膚及皮下組織，筋膜，切口上段沿臀大肌纖維走行，分離臀大肌，在切口下段，沿切開髂脛束達(dá)大粗隆下方，顯露短外旋肌群及臀中肌的后緣，屈膝并內(nèi)旋伸直髖關(guān)節(jié)緊張短外旋肌群，在閉孔內(nèi)肌和肌表面捫及坐骨神經(jīng)，分離并保護(hù)好坐骨神經(jīng)，自閉孔內(nèi)肌與肌間隙進(jìn)入，切開關(guān)節(jié)囊，顯露髖臼腫瘤，腫物的根部與髖臼后壁相連，纏繞股骨頸，形態(tài)與股骨頸相適應(yīng)，腫瘤上層覆蓋黃白色軟骨帽，纖維帽，保護(hù)好股骨頭、股骨頸、關(guān)節(jié)囊及周圍軟組織，從根部將腫物徹底切除，小心取出腫物，腫物 ( 圖 4 ) 所示：呈新月形，其形態(tài)與股骨頸相適應(yīng)，質(zhì)硬，大小約 4 cm×4 cm×8 cm，送病理，術(shù)中透視見腫物全部切除，并對(duì)標(biāo)本進(jìn)行透視( 圖 5 )，與術(shù)前 X 線片對(duì)比，進(jìn)一步證實(shí)此標(biāo)本確為此次手術(shù)切除對(duì)象，并已切除完整。髖關(guān)節(jié)活動(dòng)度好，關(guān)節(jié)穩(wěn)定。生理鹽水沖洗傷口，徹底止血，留置引流管 1 枚，清點(diǎn)敷料及器械無誤后逐層關(guān)閉切口，手術(shù)順利，術(shù)中出血量約 300 ml，術(shù)后，各足趾活動(dòng)好，無麻木，術(shù)后應(yīng)用抗生素預(yù)防感染，給予消腫止痛，活血化瘀等治療。傷口定期換藥，愈合后拆線，術(shù)后雙髖關(guān)節(jié)正位 X 線片 ( 圖 6 )示：左髖臼后壁腫瘤已切除。術(shù)后病理結(jié)果回報(bào)示：符合骨軟骨瘤 ( 圖 7 )。

圖2 術(shù)前 CT 片：左側(cè)髖臼后柱旁見團(tuán)塊狀高密度影，密度不均勻，邊界尚清，最大截面積約為 3.0 cm × 4.1 cm，左髖關(guān)節(jié)滑膜增厚，左髖關(guān)節(jié)內(nèi)見液體密度影，病變與左髖臼后柱相連，雙髖關(guān)節(jié)間隙等寬，雙側(cè)股骨頭大小、形態(tài)正常，邊緣光整Fig.2 Preoperative CT：On the left side of the posterior column of the acetabulum there was a lump with high density, uneven density, and the boundary was still clear.The largest cross-sectional area was about 3.0 cm × 4.1 cm, the left hip joint had synovial thickening of the left hip in liquid density, lesion and left posterior column of the acetabulum had a width of double hip joint space, and the size and shape of the femoral head were normal, and had smooth edge

圖3 術(shù)前 MRI 雙髖關(guān)節(jié)對(duì)稱，間隙等寬，雙側(cè)股骨頭大小、形態(tài)及信號(hào)正常，邊緣光整，雙側(cè)髖臼關(guān)節(jié)面光滑清楚。雙髖關(guān)節(jié)腔見少量長 T1長 T2信號(hào)，左髖關(guān)節(jié)滑囊內(nèi)可見多個(gè)長 T1短 T2信號(hào)影，左側(cè)滑膜明顯增厚，雙髖周圍軟組織未見明顯異常信號(hào)影Fig.3 Preoperative MRI.Both hip joints were symmetrical, and gap width, bilateral femoral head size, morphology and signal were normal, with smooth edge, bilateral acetabular articular surface was smooth and clear.Double hip joint cavity showed a small amount of long T2long T1signal, the left hip synovial bursa can be seen in a lot of long T1short T2signal shadow, the left side of the synovial thickening, the soft tissue around the 2 hips without significant abnormal signal shadow

討 論

骨軟骨瘤是臨床上最常見的良性骨腫瘤，約占良性骨腫瘤的 10%[1]，當(dāng)骨骺骺板閉合后骨軟骨瘤一般停止生長。骨軟骨瘤最常發(fā)生于長管狀骨的干骺端，關(guān)節(jié)外，尤以膝關(guān)節(jié)周圍多見，由于肌肉的牽拉，多背向關(guān)節(jié)生長。巨大骨軟骨瘤已非常少見，本例發(fā)生于髖臼后壁的單發(fā)性巨大骨軟骨瘤更是非常罕見，而且張入關(guān)節(jié)內(nèi)，臨床上更是未見有報(bào)道，長期磨合，腫瘤與股骨頭形態(tài)相適應(yīng)，瘤體位于關(guān)節(jié)內(nèi)，位置深在，不易觸及，雖然隨著腫瘤的增長會(huì)導(dǎo)致關(guān)節(jié)活動(dòng)受限，出現(xiàn)跛行或者是下蹲困難。骨軟骨瘤亦可生長于椎管內(nèi)，好發(fā)于頸胸椎，腰椎少見，通常為孤立性，逐漸壓迫馬尾和神經(jīng)根而出現(xiàn)臨床癥狀[2]。

圖4 術(shù)中大體標(biāo)本：腫物呈新月形，其形態(tài)與股骨頸相適應(yīng)，質(zhì)硬，大小約 4 cm × 4 cm × 8 cmFig.4 Gross specimen resected in operation: The tumor was crescent shaped, and its shape was suitable to the neck of the femur, and the quality was hard, and the size was about 4 cm × 4 cm × 8 cm

圖5 術(shù)中 X 線片與術(shù)前 X 線片對(duì)比，進(jìn)一步證實(shí)此標(biāo)本確為此次手術(shù)切除對(duì)象，并已切除完整Fig.5 Compared with the preoperative X-ray film, it was confirmed that the specimen was the target of operation and had been excised

圖6 術(shù)后 X 線片：左髖臼后壁腫瘤已切除Fig.6 Postoperative X-ray film: left acetabular posterior wall tumor had been removed

圖7 術(shù)后病理結(jié)果：鏡下由外至內(nèi)依次為增生的纖維、軟骨及骨組織，符合骨軟骨瘤，HE 染色 ( × 100 倍 )Fig.7 Postoperative results of pathological examination: The fibrous, cartilage and bone tissue, which were in turn from the outside to the inside, were in accordance with the osteochondroma

骨軟骨瘤的診斷依然是臨床、影像及病理三結(jié)合。X 線片表現(xiàn)：位于長骨干骺端的骨軟骨瘤的生長方向常于鄰近肌肉牽引方向一致，本例瘤體張入關(guān)節(jié)內(nèi)，與股骨頭及股骨頸長期磨合，腫瘤與股骨頭形態(tài)相適應(yīng)。X 線片雖能診斷，但位于骨盆的腫瘤位置深在，解剖關(guān)系復(fù)雜，為明確病變的性質(zhì)及其與相鄰骨骼、組織的關(guān)系，必要時(shí)須行 CT 檢查，以便在制訂手術(shù)方案時(shí)做到心中有數(shù)[3]。CT可見腫瘤骨與正常骨髓腔相通，從而明確診斷。本例患者骨盆正位 X 線片提示骨軟骨瘤或滑膜骨軟骨瘤病可能，但由于顯影重疊未能發(fā)現(xiàn)蒂部所在，因此行髖關(guān)節(jié) CT 及三維重建進(jìn)一步明確診斷及對(duì)腫瘤蒂部定位。

到目前為止手術(shù)切除是治療骨軟骨瘤的惟一方法[4]。手術(shù)指征包括[5]：壓迫神經(jīng)和血管導(dǎo)致疼痛，皮膚表面有破潰或感染，影響關(guān)節(jié)活動(dòng)，壓迫神經(jīng)引起截癱等；切除時(shí)應(yīng)從腫瘤基底部周圍部分正常骨組織開始，防止術(shù)后復(fù)發(fā)，術(shù)中將軟骨帽和基質(zhì)一起切除直到顯露正常骨質(zhì)為止[6]。對(duì)于多發(fā)骨軟骨瘤，有時(shí)會(huì)圍繞正常骨質(zhì)一圈，為防止病理骨折，可多次切除，對(duì)于切除后的骨缺損可采取自體骨和異體骨重建[7]。本例患者左髖關(guān)節(jié)活動(dòng)嚴(yán)重受限，臨床癥狀明顯，并且腫瘤巨大可能存在惡變，符合手術(shù)指征。髖關(guān)節(jié)的手術(shù)入路，有前側(cè)、外側(cè)及后外側(cè)三種，根據(jù)瘤體的部位位于髖臼的后壁故選擇左髖關(guān)節(jié)后外側(cè)手術(shù)入路，術(shù)中保護(hù)好坐骨神經(jīng)，沿髖臼后壁將腫瘤完整切除，修復(fù)關(guān)節(jié)囊及外旋肌群，關(guān)節(jié)活動(dòng)度正常且關(guān)節(jié)穩(wěn)定。

[1] Wong K, Bhagat S, Clibbon J, et al.“Globus symptoms”: rare case of giant osteochondroma of the axis treated with high cervical extrapharyngeal approach.Global Spine J, 2013, 3(2):115-118.

[2] 趙廣民, 楊滔.腰椎管內(nèi)骨軟骨瘤二例報(bào)告.解放軍醫(yī)藥雜志, 2014, 26(10):32-34.

[3] 李開華, 于秀淳.骨軟骨瘤致骨關(guān)節(jié)畸形7例診治分析.中國矯形外科雜志, 2003, 11(19):1418-1419.

[4] Humbert ET, Mehlman C, Crawford AH.Two cases of osteochondroma recurrence after surgical resection.Am J Orhop, 2001, 30(1):62-64.

[5] 王華宇.275例骨軟骨瘤的X線影像分析.重慶醫(yī)學(xué), 2010, 39(2):235-236.

[6] 王重陽, 吳偉乾, 李明嫻.股骨小轉(zhuǎn)子單發(fā)巨大骨軟骨瘤1例.中國骨傷, 2015, 28(5):461-463.

[7] Gebhart M, Vadoud Seyedi J, Lejeune F.Giant solitary oseteochondroma of the proximal humerus treated by resection and fibular autograft reconstruction.Acta Orthop Belg, 1991, 57(4):447-451.

( 本文編輯：裴艷宏 李貴存 )

Osteochondroma in the hip joint in a case

ZHANG Yuan-jian, YIN Tong-zhen, ZHANG Wen-lu.
Department of Bone and Soft Tissue Tumors, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, Hebei, 061000, PRC

Objective To study and understand morphology and growth pattern of osteochondroma in the hip joint.Methods The patient was a female, 48 years old, and she had left hip pain and restricted motility for 10 years, which were aggravated for 2 months until admission.Positive preoperative preparation before admission improved the results of relevant laboratory tests, X, CT, MRI.Tumor resection was performed after general anesthesia.Results The tumor was crescent shaped, its shape and the neck of the femur were adapted, quality was hard, size was about 4 cm × 4 cm × 8 cm, and the sample was sent to pathology lab.The intraoperative X-ray showed the tumor resection.Conclusions The tumor is consistent with the osteochondroma.

Hip joint; Osteochondroma; Bone neoplasms

10.3969/j.issn.2095-252X.2000.12.015

R738.3

061000 河北，滄州中西醫(yī)結(jié)合醫(yī)院骨一科骨與軟組織腫瘤科

張文路，Email: 84513692@qq.com

2016-08-20 )