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Article(id=1322190378955030710, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322190358751069178, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202504095, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1745337600000, receivedDateStr=2025-04-23, revisedDate=1749744000000, revisedDateStr=2025-06-13, acceptedDate=null, acceptedDateStr=null, onlineDate=1793164351451, onlineDateStr=2026-10-28, pubDate=1757865600000, pubDateStr=2025-09-15, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793164351451, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793164351451, creator=13701087609, updateTime=1793164351451, updator=13701087609, issue=Issue{id=1322190358751069178, tenantId=1146029695717560320, journalId=1319373162502258839, year='2025', volume='47', issue='17', pageStart='1981', pageEnd='2144', issueExtLink='null', onlineDate='null', pubDate='1757865600000', pubDateStr='2025-09-15', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1793164346635, creator='13701087609', updateTime=1793164560388, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322191255602319722, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322190358751069178, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322191255602319723, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322190358751069178, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=2115, endPage=2123, ext={EN=ArticleExt(id=1322190379206688951, articleId=1322190378955030710, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Application of 3D-printed customized prostheses in limb-salvage surgery for pediatric osteosarcoma of the distal femur: a case series study, columnId=1320435174995772212, journalTitle=Journal of Army Medical University, columnName=Clinical Medicine, runingTitle=null, highlight=null, articleAbstract=
Objective‍

To evaluate the short-term efficacy of 3D-printed customized prostheses in limb-salvage surgery for pediatric distal femoral osteosarcoma.

Methods‍

A single-center retrospective study was conducted on the outcomes of 19 eligible children at the Affiliated Children's Hospital of Chongqing Medical University from May 2021 to February 2025. Among them, 9 cases were in the epiphysis-preserving group and received 3D-printed personalized epiphysis-preserving prosthesis implantation; 10 cases were in the hinge group and underwent 3D-printed individual hinge prosthesis implantation. Their basic clinical data, perioperative data, and follow-up information were collected and analyzed.

Results‍

All the 19 subjected patients completed the surgeries as preoperatively planned. The knee joint function of the children recovered well after surgery. In the epiphysis-preserving group, there were 8 males and 1 female, at an average age of 11.05±2.75 years. During a follow-up time of 21.67±15.87 months, 8 cases obtained disease-free survival, with a mean Musculoskeletal Tumor Society (MSTS) score of 27.56±1.33, and the left 1 case deceased. The hinge group included 4 males and 6 females, at an age of 10.12±2.30 years, and they were followed up for 22.30±11.23 months. For the 7 cases with disease-free survival, their MSTS score was 25.30±2.21, and the other 3 cases dead.

Conclusion‍

In the limb salvage treatment of children with osteosarcoma in the distal femur, 3D-printed personalized prosthesis implantation achieves satisfactory short-term outcome.

, authors=Fusheng QIAN, Jiaqiang QIN, authorsList=Fusheng QIAN, Jiaqiang QIN, authorCompany=null, correspAuthors=Jiaqiang QIN, authorNote=null, correspAuthorsNote=null, copyrightStatement=© 2025 Journal of Army Medical University, copyrightOwner=Editorial Office of Journal of Army Medical University, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322190380574032068, articleId=1322190378955030710, tenantId=1146029695717560320, journalId=1319373162502258839, language=CN, title=3D打印个性化假体应用于儿童股骨远端骨肉瘤保肢术的病例系列报道, columnId=1322185541475488183, journalTitle=陆军军医大学学报, columnName=临床医学, runingTitle=null, highlight=null, articleAbstract=
目的

总结3D打印个性化假体在儿童股骨远端骨肉瘤保肢手术的短期疗效。

方法

总结重庆医科大学附属儿童医院2021年5月至2025年2月行3D打印个性化假体股骨远端骨肉瘤保肢手术的19例患儿的疗效，其中9例为保骺组，行3D打印个性化保骺假体植入术；10例为铰链组，行3D打印个体铰链式假体植入术。收集并分析患者的基本临床资料、围术期资料和随访情况。

结果

19例患儿均按术前规划完成手术，术后患儿膝关节功能恢复良好。其中保骺组（n=9）：男性患儿8例，女性患儿1例，年龄（11.05±2.75）岁，随访时间（21.67±15.87）月，无瘤生存8例，死亡1例，美国骨骼肿瘤协会（Musculoskeletal Tumor Society，MSTS）评分为（27.56±1.33）分。铰链组（n=10）：男性患儿4例，女性患儿6例，年龄（10.12±2.30）岁，随访时间（22.30±11.23）月，无瘤生存7例，死亡3例，MSTS评分为（25.30±2.21）分。

结论

在儿童股骨远端骨肉瘤保肢治疗中，3D打印个性化假体植入术术后短期随访结果满意。

, authors=钱福生, 覃佳强, authorsList=钱福生, 覃佳强, authorCompany=null, correspAuthors=覃佳强, authorNote=null, correspAuthorsNote=
覃佳强，E-mail：
QIN Jiaqiang，E-mail：
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Orthop Surg，2016，8（2）：111-121., articleTitle=Biological reconstruction in bone sarcomas：lessons from three decades of experience, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1322190380796330181, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, xref=1, ext=[AuthorCompanyExt(id=1322190380804718790, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, companyId=1322190380796330181, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of Orthopedics，Affiliated Children’s Hospital，Chongqing Medical University，Chongqing，China), AuthorCompanyExt(id=1322190380817301703, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, companyId=1322190380796330181, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1重庆医科大学附属儿童医院骨科，重庆)])], figs=[ArticleFig(id=1322190381945569498, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Figure 1, caption=Flowchart of 3D-printed prosthetic manufacturing process, figureFileSmall=TusZ4AzLuyss42KPJUVjpg==, figureFileBig=2emVuFZTg7Y8q2oNmXpPXg==, tableContent=null), ArticleFig(id=1322190382054621403, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=图1, caption=3D打印假体制作流程图, figureFileSmall=TusZ4AzLuyss42KPJUVjpg==, figureFileBig=2emVuFZTg7Y8q2oNmXpPXg==, tableContent=null), ArticleFig(id=1322190382318862556, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Figure 2, caption=Gross view of osteosarcoma in the distal femur （A） and 3D-printed customized epiphysis-preserving prosthesis （B）, figureFileSmall=VL8Y//WSoNPfUZNRYr56Kg==, figureFileBig=vc9hwDCAtT+17p1KsOy4Tw==, tableContent=null), ArticleFig(id=1322190382394360029, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=图2, caption=股骨远端骨肉瘤大体图（A）及3D打印个性化保骺假体（B）, figureFileSmall=VL8Y//WSoNPfUZNRYr56Kg==, figureFileBig=vc9hwDCAtT+17p1KsOy4Tw==, tableContent=null), ArticleFig(id=1322190382465663198, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Figure 3, caption=Schematic diagram of the 3D-printed customized epiphysis-preserving prosthesis （A） and hinge prosthesis （B）, figureFileSmall=yILwDf8BycqqGaeHWfV1FQ==, figureFileBig=d3NBdcVG1/KmEGsRQm5Zzw==, tableContent=null), ArticleFig(id=1322190382536966367, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=图3, caption=3D打印个性化保骺假体安装图（A）及铰链式假体安装图（B）, figureFileSmall=yILwDf8BycqqGaeHWfV1FQ==, figureFileBig=d3NBdcVG1/KmEGsRQm5Zzw==, tableContent=null), ArticleFig(id=1322190382604075232, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Figure 4, caption=Osseointegration at the prosthesis-bone interface in the epiphysis-preserving cohort （A） and hinge prosthesis cohort （B） at 2 months postoperatively, figureFileSmall=avw4A94OuJqGtTMh+WXesQ==, figureFileBig=0pCUOHAX9I2Vr+ACwfXPzA==, tableContent=null), ArticleFig(id=1322190382671184097, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=图4, caption=保骺组（A）及铰链组（B）术后2月假体-骨平面整合情况, figureFileSmall=avw4A94OuJqGtTMh+WXesQ==, figureFileBig=0pCUOHAX9I2Vr+ACwfXPzA==, tableContent=null), ArticleFig(id=1322190382738292962, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Figure 5, caption=A case of epiphysis-preserving prosthesis implantation, figureFileSmall=T2YFOGlid4G/V1AM/grMbw==, figureFileBig=Rm4VvwbWwkYXmnVGO6707Q==, tableContent=null), ArticleFig(id=1322190382809596131, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=图5, caption=保骺式假体植入病例

A~D：Preoperative radiographic （A），CT （B），MRI （C），and postoperative radiographic （D） images of a pediatric patient，arrows indicate tumor location； E and F：Knee function photographs during the final follow-up

, figureFileSmall=T2YFOGlid4G/V1AM/grMbw==, figureFileBig=Rm4VvwbWwkYXmnVGO6707Q==, tableContent=null), ArticleFig(id=1322190382889287908, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Figure 6, caption=A case of hinged prosthesis implantation, figureFileSmall=6jMASPlehyFtCtzL3tOV1g==, figureFileBig=cDRwmiRBZO1XH5mFeDsZDQ==, tableContent=null), ArticleFig(id=1322190382964785381, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=图6, caption=铰链式假体植入病例

A~D：Preoperative radiographic （A），CT （B），MRI （C），and postoperative radiographic （D） images of a pediatric patient，arrows indicate tumor location；E and F：Knee function photographs during the final follow-up

, figureFileSmall=6jMASPlehyFtCtzL3tOV1g==, figureFileBig=cDRwmiRBZO1XH5mFeDsZDQ==, tableContent=null), ArticleFig(id=1322190383052865766, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Table 1, caption=

Basic information of the subjected patients

, figureFileSmall=null, figureFileBig=null, tableContent=
ID NO.GenderAge/yearsLesion SiteBiopsy ResultGroupStage（AJCC）
01Female10.5LOB-OSEPⅢ
02Male10.6LOB-OSEPⅡ
03Male11.8ROB-OSEPⅢ
04Male9ROB-OSEPⅢ
05Male14RCB-OSEPⅣ
06Male11ROB-OSEPⅢ
07Male16LOB-OSEPⅢ
08Male10LOB-OSEPⅡ
09Male6.5LOB-OSEPⅡ
10Male11.9ROB-OSHingeⅢ
11Male10.8ROB-OSHingeⅢ
12Female13.3LOB-OSHingeⅣ
13Female5.7LOB-OSHingeⅡ
14Female8.3LCB-OSHingeⅢ
15Male12.8LOB-OSHingeⅢ
16Female9ROB-OSHingeⅢ
17Female9.8ROB-OSHingeⅣ
18Male9LOB-OSHingeⅣ
19Female10.7LFB-OSHingeⅡ
), ArticleFig(id=1322190383136751847, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=表1, caption=

患者基本资料汇总

, figureFileSmall=null, figureFileBig=null, tableContent=
ID NO.GenderAge/yearsLesion SiteBiopsy ResultGroupStage（AJCC）
01Female10.5LOB-OSEPⅢ
02Male10.6LOB-OSEPⅡ
03Male11.8ROB-OSEPⅢ
04Male9ROB-OSEPⅢ
05Male14RCB-OSEPⅣ
06Male11ROB-OSEPⅢ
07Male16LOB-OSEPⅢ
08Male10LOB-OSEPⅡ
09Male6.5LOB-OSEPⅡ
10Male11.9ROB-OSHingeⅢ
11Male10.8ROB-OSHingeⅢ
12Female13.3LOB-OSHingeⅣ
13Female5.7LOB-OSHingeⅡ
14Female8.3LCB-OSHingeⅢ
15Male12.8LOB-OSHingeⅢ
16Female9ROB-OSHingeⅢ
17Female9.8ROB-OSHingeⅣ
18Male9LOB-OSHingeⅣ
19Female10.7LFB-OSHingeⅡ
), ArticleFig(id=1322190383237415144, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=EN, label=Table 2, caption=

Perioperative data and follow-up outcome［x¯±s，M（P25，P75），n（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
ItemsEP Group（n=9）Hinge Group（n=10）
Preoperative chemotherapy cycles5（4.00，5.00）6（5.25，7.00）
Original limb length （mechanical axis）/cm40.09±4.3136.45±6.54
Osteotomy length/cm20.58±3.4519.50±4.77
Operation duration/min360（320，360）325（300，363）
Intraoperative blood loss/mL400（400，600）500（263，800）
Complications
None9（100）8（80.00）
Present02（20.00）
Oncologic outcomes
Deceased1（11）3（30）
Disease-free survival8（89）7（70）
MSTS score27.56±1.3325.30± 2.21
), ArticleFig(id=1322190383304524009, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322190378955030710, language=CN, label=表2, caption=

围手术期资料及随访结果［x¯±s，M（P25，P75），例（％）］

, figureFileSmall=null, figureFileBig=null, tableContent=
ItemsEP Group（n=9）Hinge Group（n=10）
Preoperative chemotherapy cycles5（4.00，5.00）6（5.25，7.00）
Original limb length （mechanical axis）/cm40.09±4.3136.45±6.54
Osteotomy length/cm20.58±3.4519.50±4.77
Operation duration/min360（320，360）325（300，363）
Intraoperative blood loss/mL400（400，600）500（263，800）
Complications
None9（100）8（80.00）
Present02（20.00）
Oncologic outcomes
Deceased1（11）3（30）
Disease-free survival8（89）7（70）
MSTS score27.56±1.3325.30± 2.21
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3D打印个性化假体应用于儿童股骨远端骨肉瘤保肢术的病例系列报道
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钱福生 , 覃佳强
陆军军医大学学报 | 临床医学 2025,47(17): 2115-2123
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陆军军医大学学报 |临床医学 2025 , 47 (17) : 2115 -2123
3D打印个性化假体应用于儿童股骨远端骨肉瘤保肢术的病例系列报道
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钱福生, 覃佳强
作者信息
  • 1重庆医科大学附属儿童医院骨科，重庆
通讯作者:
覃佳强，E-mail：
QIN Jiaqiang，E-mail：
Application of 3D-printed customized prostheses in limb-salvage surgery for pediatric osteosarcoma of the distal femur: a case series study
Fusheng QIAN, Jiaqiang QIN
Affiliations
  • 1Department of Orthopedics，Affiliated Children’s Hospital，Chongqing Medical University，Chongqing，China
出版时间: 2025-09-15 doi: 10.16016/j.2097-0927.202504095
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摘要
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目的

总结3D打印个性化假体在儿童股骨远端骨肉瘤保肢手术的短期疗效。

方法

总结重庆医科大学附属儿童医院2021年5月至2025年2月行3D打印个性化假体股骨远端骨肉瘤保肢手术的19例患儿的疗效，其中9例为保骺组，行3D打印个性化保骺假体植入术；10例为铰链组，行3D打印个体铰链式假体植入术。收集并分析患者的基本临床资料、围术期资料和随访情况。

结果

19例患儿均按术前规划完成手术，术后患儿膝关节功能恢复良好。其中保骺组（n=9）：男性患儿8例，女性患儿1例，年龄（11.05±2.75）岁，随访时间（21.67±15.87）月，无瘤生存8例，死亡1例，美国骨骼肿瘤协会（Musculoskeletal Tumor Society，MSTS）评分为（27.56±1.33）分。铰链组（n=10）：男性患儿4例，女性患儿6例，年龄（10.12±2.30）岁，随访时间（22.30±11.23）月，无瘤生存7例，死亡3例，MSTS评分为（25.30±2.21）分。

结论

在儿童股骨远端骨肉瘤保肢治疗中，3D打印个性化假体植入术术后短期随访结果满意。

3D打印  /  假体设计  /  骨肉瘤  /  保肢术
Objective‍

To evaluate the short-term efficacy of 3D-printed customized prostheses in limb-salvage surgery for pediatric distal femoral osteosarcoma.

Methods‍

A single-center retrospective study was conducted on the outcomes of 19 eligible children at the Affiliated Children's Hospital of Chongqing Medical University from May 2021 to February 2025. Among them, 9 cases were in the epiphysis-preserving group and received 3D-printed personalized epiphysis-preserving prosthesis implantation; 10 cases were in the hinge group and underwent 3D-printed individual hinge prosthesis implantation. Their basic clinical data, perioperative data, and follow-up information were collected and analyzed.

Results‍

All the 19 subjected patients completed the surgeries as preoperatively planned. The knee joint function of the children recovered well after surgery. In the epiphysis-preserving group, there were 8 males and 1 female, at an average age of 11.05±2.75 years. During a follow-up time of 21.67±15.87 months, 8 cases obtained disease-free survival, with a mean Musculoskeletal Tumor Society (MSTS) score of 27.56±1.33, and the left 1 case deceased. The hinge group included 4 males and 6 females, at an age of 10.12±2.30 years, and they were followed up for 22.30±11.23 months. For the 7 cases with disease-free survival, their MSTS score was 25.30±2.21, and the other 3 cases dead.

Conclusion‍

In the limb salvage treatment of children with osteosarcoma in the distal femur, 3D-printed personalized prosthesis implantation achieves satisfactory short-term outcome.

printing，three-dimensional  /  prosthesis design  /  osteosarcoma  /  limb salvage
钱福生, 覃佳强. 3D打印个性化假体应用于儿童股骨远端骨肉瘤保肢术的病例系列报道. 陆军军医大学学报, 2025 , 47 (17) : 2115 -2123 . DOI: 10.16016/j.2097-0927.202504095
Fusheng QIAN, Jiaqiang QIN. Application of 3D-printed customized prostheses in limb-salvage surgery for pediatric osteosarcoma of the distal femur: a case series study[J]. Journal of Army Medical University, 2025 , 47 (17) : 2115 -2123 . DOI: 10.16016/j.2097-0927.202504095
正文
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骨肉瘤（osteosarcoma，OS）是最常见的原发性恶性骨肿瘤，好发于青少年［1-2］四肢长骨的干骺端，如股骨远端、胫骨近端、股骨近端和肱骨近端等［3］。据报道，约60%的患者在10~20岁［1］，骨肉瘤也被认为是这个年龄段排名第二的致死因素。骨肉瘤的年发病率2/100万~3/100万［4-5］。虽然发病率较低，但骨肉瘤恶性程度高，侵袭性强，有较高的残疾率和病死率，严重影响青少年和儿童生存率和生存质量。
在儿童和青少年患者中，骨肉瘤常发生于股骨远端及胫骨近端，即膝关节周围。随着新辅助化疗在骨肉瘤治疗中的应用，临床上绝大多数患儿可实施保肢治疗，然而传统保肢手术常需牺牲骨骺，导致患儿肢体不等长、关节功能障碍等远期并发症。儿童骨骺的保留不仅是功能保全的关键，更是目前儿童骨肿瘤外科领域的的技术难点。随着3D打印技术在临床上的发展与应用，目前可以通过3D打印技术制作出与患者肢体适配的个性化人工假体。本研究通过回顾分析在我院2021年5月至2025年2月，接受3D打印个性化假体进行保肢治疗的儿童股骨远端骨肉瘤患者的临床资料，系统评估保骺式假体在儿童骨肉瘤中的短期功能预后，进一步验证基于MRI肿瘤边界的个性化保肢手术适应症标准，并建立3D打印个性化假体设计与骨骺生长潜能保留的关联性模型，旨在为儿童骨肉瘤的精准保肢治疗提供新策略。
1　资料与方法
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1.1　研究对象
本研究为病例系列报道，纳入于2021年5月至2025年2月在重庆医科大学附属儿童医院骨科接受3D打印个性化假体进行保肢治疗的股骨远端骨肉瘤患儿，随访截止时间为2025年2月，总计纳入病例数为19例。依照美国癌症联合委员会（American Joint Committee on Cancer，AJCC）分期系统对2组肿瘤患儿进行分期［6］，根据术前磁共振成像（magnetic resonance imaging，MRI），骨肿瘤边缘距离骺板≥1 cm［7］，行3D打印个性化保骺式假体植入术，纳入保骺组，共9例；骨肿瘤边缘距离骺板<1 cm者，被认为无法保留骨骺，行3D打印个体铰链式假体植入术，纳入铰链组，共10例。
1.2　纳入和排除标准
纳入标准：①病理诊断确认为股骨远端骨肉瘤；②接受≥4周期新辅助化疗；③采用3D打印个性化假体重建骨缺损，实施保肢手术；④随访时间≥4月。排除标准：①合并其他原发恶性肿瘤；②术前皮肤严重感染或血管神经侵犯；③术中转为截肢；④随访期间失访或关键资料不完整。本研究已通过重庆医科大学附属儿童医院伦理委员会批准（CHCMU-XJS-2021-04），获得所有患儿监护人的知情同意并签署知情同意书。
1.3　术前新辅助化疗
经病理活检确诊，全院多学科会诊讨论制定治疗方案，患者术前、术后均接受大剂量甲氨蝶呤（high-dose methotrexate，HD-MTX）、多柔比星（doxorubicin，ADM）联合顺铂（cisplatin，DDP）的化疗方案（MAP方案）［8-10］，瘤体均不同程度缩小、坏死。
1.4　术前规划及3D假体制备
所有患儿完成双下肢薄层CT以及CT血管造影（computed tomography angiography，CTA）、MRI。CT采集患者的骨骼数据，以便于进行三维打印模型构建；MRI有助于判断髓腔内肿瘤侵袭范围，为骨肉瘤的精确切除提供依据，确定非关节端于距离肿瘤边界3~5 cm处进行截骨，从而获得安全的肿瘤外界［7-13］；结合相关文献提示MRI显示肿瘤边界距离骺板≥1 cm者，认为可选择保留骨骺［14］。
3D打印假体流程包括：图像采集［采集患者术前CT扫描的原始DICOM格式数据，层厚（0.625 mm）］、三维数字建模（数据导入Mimics软件中，进行三维重建）、建立树脂模型（截取拟手术区域，采用医用树脂，1∶1重建手术区域模型）、计算机模拟手术（在Mimics及CAD软件中进行操作，测量需切除区域的相关参数，绘制切除区域的CAD外观模型）、模型再验证［将CAD模型回嵌入原始三维数字建模模型中，该模型内部为通体多孔结构，外周为力学性能更强的仿人体骨小梁结构，通过布尔运算验证接触面匹配度及精准性（误差<0.2 mm）］、内固定方案制定（在三维数字建模模型中，模拟置入合适尺寸的螺钉，测量并精准确定其进针点、倾斜角、长度等参数）、假体尺寸制定（采用3D打印软件精确制作个性化假体，并置入三维数字模型中验证。选择最佳孔径、孔隙率和形状，同时在假体上选择合适的进针点和进针角度）、个性化假体参数确定［根据不同患者具体情况，采用合适力学强度的假体及其尺寸，并预留一定范围变量（3~5 mm）以适应术中切除范围变化］、假体3D打印［将个性化假体相关参数导入后，使用ACARM打印机进行校准后打印（材料为Ti6Al4V钛合金粉末）］以及假体冷却及清洗（打印后冷却10 h至室温后开炉取出假体，充分消除残余应力，分别采用冲枪冲洗以及超声波水洗确保该假体未残留打印粉末）。
术中假体置入步骤：①假体置入：术中切除并取出肿瘤后与打印成品对比再次验证并选择合适型号的假体；②螺钉置入：假体置入完毕后，按照术前测量数据选择合适尺寸的螺钉，沿假体预设进针钉道置入螺钉（图1）。
1.5　手术方法及术后护理
手术在全身麻醉下进行，术中间断使用气压止血带减少术中出血及充分暴露术野，取原病检切口作为手术入路，切除原有活检通道。保护重要神经，精细分离及保护大血管前提下，尽可能在肿瘤瘤体的囊外进行，完整切除肿瘤包膜及周围反应带，术中快速病理确认切缘阴性。按照术前规划，截骨近端均在距离肿瘤3~5 cm的位置进行截骨。而截骨远端分为：①保骺组的截骨远端为股骨远端骺线处进行截骨；②铰链组的截骨远端为完整切除股骨远端，同时需切除半月板及前后交叉韧带，并暴露胫骨平台，为安装铰链式假体做好准备。将股骨远端骨肿瘤完整切除后，均需使用浓度0.2 mg/mL的卡铂液对病灶区域浸泡30 min，同时软组织重建是保肢手术中核心环节之一，术中需预留足够的皮肤和软组织覆盖假体进行重建。最后，植入术前准备的3D打印可扩展假体。假体安装后，使用保留的皮肤和软组织覆盖假体并进行功能重建（图2）。术中X线透视确定假体位置良好，术中活动关节明确关节活动度良好。充分冲洗术区，确切止血，放置引流管后逐层缝合手术切口。在本研究中的所有患者均由同一位外科医生进行手术，术前规划示意图见图3。
患儿术后早期康复要点：术后24 h开始CPM机辅助被动活动（0°~30°），支具固定3周后逐步增加活动范围。患儿术后逐渐负重训练，术后4周部分负重（20%体质量），6周过渡至完全负重，定期X线监测假体-骨界面整合情况。
1.6　数据收集及随访项目
对纳入研究的患儿，依次记录基本信息、术前化疗次数、患侧股骨骨性长度（股骨机械轴长度）、手术时长、术中出血量、截骨长度、住院期间并发症。出院后首次随访时间为术后1个月，随访项目为双下肢全长位片。根据首次复查结果，后续依次于3月、6月、12月进行门诊复查，同时每4个月复查胸部CT、双下肢MRI、肿瘤局部超声评估肿瘤复发，同时通过电话对患儿及家属进行随访，末次随访采用美国骨骼肿瘤协会评分（Musculoskeletal Tumor Society，MSTS）评估患者术后肢体功能（总分30分，分数越高，功能越好）［15］，为确保研究质量，数据收集及患儿随访均由同一骨科医生完成。
1.7　统计学分析
所有数据采用SPSS 27.0统计软件进行统计学分析，其中符合正态分布的计量资料用x¯±s描述，偏态分布的计量资料采用M（P25，P75）描述，计数资料采用例（%）描述。
2　结果
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2.1　患者基本资料
本研究共纳入19例患儿，分为保骺组及铰链组，对患儿性别、年龄、部位、病检结果、肿瘤分期进行统计，基本资料见表1。
2.2　围术期情况
所有患者按术前规划顺利完成手术。保骺组患儿年龄为（11.05±2.75）岁，术前化疗次数中位数为5次；手术时长中位数360 min（包括患儿麻醉操作时间）；患肢股骨骨性长度（40.09±4.31）cm，截骨长度（20.58±3.45）cm；术中失血量中位数400 mL；术后未出现并发症。铰链组患儿年龄为（10.1±2.30）岁，术前化疗次数中位数6次；手术时长中位数325 min（包括患儿麻醉操作时间）；患肢股骨骨性长度（36.45±6.54）cm，截骨长度（19.50±4.77）cm；术中失血量中位数500 mL；术后本组患儿2例出现皮肤愈合不良，在院期间经积极伤口清创换药后愈合（表2）。
2.3　随访结果
入组患儿顺利完成随访，至末次随访时2组均未出现假体松动、脱位、断裂等假体相关并发症。术后2月监测假体-骨平面整合良好（图4）。2组存活患儿均满足日常基本生活需求，可平地行走、上下楼梯、慢跑。
保骺组患儿随访时间（21.67±15.87）个月（6~45个月）：至末次随访时，MSTS评分为（27.56±1.33）分（92%，范围26~30分）。9例患儿无瘤生存8例（89%），因肿瘤进展而死亡1例（11%，Ⅳ期，肿瘤远端骨骺转移）。
铰链组患儿随访时间（22.30±11.23）个月（4~37个月）；至末次随访时，MSTS评分为（25.30±2.21）分（84%，范围21~28分）。10例患儿无瘤生存7例（70%），因肿瘤进展而死亡3例（30%；肿瘤膝关节后方转移1例，Ⅲ期；肿瘤肺部转移2例，均为Ⅲ期）。
2.4　典型病例
病例1 ：男性患儿，11岁5月，诊断为右股骨远端骨肉瘤。MRI提示瘤缘距骺板距离为1.1 cm，选择行3D打印个性化可延长保骺式假体植入（图5）。至本研究末次随访时，患儿膝关节活动良好，双下肢未见明显不等长。
病例2：女性患儿，13岁，诊断左股骨远端骨肉瘤。核磁显示肿瘤已完全突破骨骺线，行3D打印个性化可延长铰链式假体植入（图6）。至本研究末次随访时，患儿膝关节功能满意，无明显双下肢不等长。
3　讨论
收起
3.1　骨肉瘤保肢治疗的现状与3D打印在骨肉瘤治疗中的价值
随着新辅助化疗的开展以及临床应用，骨肉瘤患者的5年生存率由截肢术的<20％提高至60％~80％，同时保肢手术的成功率也达到了70%~80%［16］。保肢手术已经成为目前骨肉瘤的治疗主流。据统计［17］，儿童骨肉瘤约有70%发生于膝关节周围，在骨肉瘤切除后，尽量保留自体关节能够使患者保留正常膝关节结构，从而使患者具有更佳的本体感觉和更优的关节活动度［14-21］。目前对于骨肉瘤切除后的骨缺损，重建方法有很多，如Masquelet技术、肿瘤灭活骨以及同种异体骨再植等，但各有利弊［22-25］。
随着3D打印技术在临床中的广泛应用，3D打印个性化假体在骨肉瘤治疗中的优势逐渐凸显，对骨肉瘤切除后骨缺损的重建不仅可以进行结构重建，而且可以进行功能重建，而利用不同的材料打印出来的载药骨活性支架也能为骨肉瘤切除后的重建骨缺损、防止肿瘤复发、抑制细菌感染及促进骨生长提供更多的选择［26］。3D打印个性化假体置换术已广泛应用于膝关节周围的骨肉瘤患者中［27］。有相关研究证明，假体置换术后患者在短期内能获得较好的关节功能［28］，但也有学者指出此类手术后发生较多并发症，如假体周围感染、肿瘤型假体松动、假体周围骨折和双侧肢体不等长等［29-31］。
3.2　儿童骨骺保留的困境
对于儿童膝关节置换术中切除了股骨以及胫骨的骨骺，从而破坏青少年下肢的生长潜力［32］。在本研究中，将保留了股骨远端及胫骨近端骨骺的病例纳入保骺组，将完全切除股骨远端骨骺的病例纳入铰链组。考虑到对于铰链组而言，胫骨近端骨骺保留了下来，但3D打印铰链式假体的细柄穿透了近端骨骺，远期胫骨近端骨骺的生长潜能是否完全丧失或部分保留，这是本研究将进行更长期随访与统计的重点，在本研究的末次随访中并未观察到明显的肢体长度不等长。本研究在设计假体时，预留了可延长模块，为将来儿童的延长需求提供技术储备。
3.3　保骺手术安全边界的探索与验证
目前对于儿童骨肉瘤患者保留骨骺的外科手术安全边界的确定，暂时没有一个统一的标准。GONG等［11］认为在肿瘤未突破骺板的患儿，均于骺板处截骨。KAWAGUCHI等［13］认为术前MRI显示肿瘤距骨骺>2 cm者可实施保留骨骺及关节的手术。而WONG等［33］则认为骨肉瘤病变离骨骺线＞1 cm是实施保留骨骺的外科手术切除的安全边界。本研究就是在此理论前提下精准筛选适应症，MRI上显示肿瘤边界大于骺线≥1 cm者，可在无远处转移的情况下开展保骺保肢手术，对该标准的临床可行性进行了有效验证，这也是本研究的核心贡献之一。
3.4　术后短期疗效与初步发现
本研究描述了一种股骨远端骨肉瘤患儿保肢治疗的手术方式，术前精准匹配适应症，分别使用3D打印个性化保骺假体及铰链式假体进行骨缺损重建，假体设计为内部多孔、外周仿人体骨小梁结构，术后2月假体-骨平面骨长入，整合良好。结果表明，保骺组患儿未出现短期并发症，铰链式假体患儿短期出现2例皮肤愈合不良，经对症处理后均痊愈出院，这可能与术中大量切除周围软组织及活检瘤道导致软组织覆盖不足有较大关联。自从开展3D打印个性化假体置换术以来，本研究并未观察到假体松动或断裂等假体相关并发症。此外，观察到4例患儿因复发、转移而死亡，术前肿瘤分期至少为Ⅲ期。其中保骺组远处转移1例；铰链组3例，2例为远处转移，1例为术后未遵医嘱完成术后巩固化疗，半年后肿瘤局部复发，最终导致死亡。这可能与肿瘤突破骨骺后播散至关节腔内相关，提示骨骺可能具有潜在的肿瘤屏障效应，同时有基础研究显示骺板软骨中血管内皮抑制素浓度是干骺端骨质的数倍，这种内源性抗血管生成因子可能通过抑制肿瘤新生血管形成延缓局部侵袭［34］。这也初步表明，保留骨骺不仅关乎功能，亦可能与更优的肿瘤控制和生存获益相关。同时这些结果也再次验证患儿预后与肿瘤分期呈现相关性，手术方式选择应在严格遵循保骺适应症标准。
3.5　膝关节保留的功能优势与机制
SAN-JULIAN等［35］回顾过去30年行骨肿瘤保肢术的患者，发现从远期疗效来说保留关节比关节融合，以及全膝关节肿瘤假体置入具有更高的膝关节功能（MSTS评分更高）。在本研究中，保骺组患儿MSTS评分为（27.56±1.33）分，铰链组患儿MSTS评分为（25.30±2.21）分，患者无论是否无瘤生存或带瘤生存，都仍然保留了自体膝关节，有良好的关节功能评分和生活质量，这一结果可能与以下机制相关：①保留骨骺维持了膝关节生理性旋转轴与韧带解剖止点，通过本体感觉传导优化了动态稳定性；②骺板软骨的应力缓冲作用降低了假体-骨界面微动性磨损风险；③术中完整保留的股骨远端生长板虽已失去纵向生长潜能，但其在冠状面和矢状面的残余生长调节能力可能改善远期假体匹配度。这些保留膝关节的肿瘤切除术保留了正常的关节解剖结构，导致重建后更好的本体感觉和更好的关节功能，这也意味着将为患儿带来更好的外观和生活质量。
最后，与类似研究相比，本研究的回顾性数据显示更为积极的结果，然而，本研究仍存在一定的局限性：①随访时间短，对于儿童骨肉瘤膝关节重建后更有可能出现的肢体长度差异，无法得到可靠的数据。②样本量小，纳入病例数仅为19例。③本研究为单中心开展，缺乏传统保留骨骺手术方式的患儿数据。无法在2组别间进行有意义的对比，不能得出关于本手术方式进一步临床使用的任何绝对结论。
综上所述，在儿童股骨远端骨肉瘤保肢治疗中，3D打印个性化假体植入术术后短期随访结果满意，远期效果值得期待。

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doi: 10.16016/j.2097-0927.202504095
  • 接收时间：2025-04-23
  • 首发时间：2026-10-28
  • 出版时间：2025-09-15
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  • 收稿日期：2025-04-23
  • 修回日期：2025-06-13
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    1重庆医科大学附属儿童医院骨科，重庆

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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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