髋关节内骨软骨瘤一例报告

张远鉴 尹同珍 张文路

髋关节内骨软骨瘤一例报告

张远鉴 尹同珍 张文路

髋关节； 骨软骨瘤；骨肿瘤

骨软骨瘤是一种常见的原发性良性骨肿瘤，多见于儿童和青少年，常见累及的部位是股骨远端、桡骨近端、胫骨近端、腓骨近端、腓胫骨远端的干骺端，由于肌肉的牵拉，多背向关节生长，巨大骨软骨瘤非常少见，位于关节内的肿瘤更是罕见报道。

临床资料

患者，女，48 岁，左髋部疼痛、活动受限 10 年，加重 2 个月，2016 年 1 月 21 日入院。患者 10 年前出现左髋部疼痛，劳累后加重，休息后缓解，未予特殊处理，2 个月前左髋关节疼痛加重，下蹲困难，不能盘腿，体力劳动后明显。查体：双髋关节未见明显畸形，未触及明显肿物，左髋关节屈曲活动正常，外展外旋活动明显受限，感觉、肌力及肌张力正常。X 线片 ( 图 1 ) 示：左髋关节处可见团块状高密度影，密度不均匀。CT ( 图 2 ) 示：左侧髋臼后柱旁见团块状高密度影，密度不均匀，边界尚清，最大截面积约为 3.0 cm×4.1 cm，左髋关节滑膜增厚，左髋关节内见液体密度影，病变与左髋臼后柱相连，双髋关节间隙等宽，双侧股骨头大小、形态正常，边缘光整。MRI ( 图 3 ) 示：双髋关节对称，间隙等宽，双侧股骨头大小、形态及信号正常，边缘光整，双侧髋臼关节面光滑清楚。双髋关节腔见少量长 T1长 T2信号，左髋关节滑囊内可见多个长 T1短 T2信号影，左侧滑膜明显增厚，双髋周围软组织未见明显异常信号影。初步诊断：左髋臼后壁肿瘤，骨软骨瘤可能性大。

图1 术前 X 线片；左髋关节处可见团块状高密度影，密度不均匀Fig.1 Preoperative X-ray film：The left hip joint showed mass like high density shadow, and the density was not uniform

入院后积极术前准备，完善术前相关化验检查，未见明显手术禁忌，在全麻下行左髋臼后壁肿瘤切除术。全麻满意后，取右侧卧位，常规术区消毒，取左髋关节后外侧切口，长约 16 cm，依次切开皮肤及皮下组织，筋膜，切口上段沿臀大肌纤维走行，分离臀大肌，在切口下段，沿切开髂胫束达大粗隆下方，显露短外旋肌群及臀中肌的后缘，屈膝并内旋伸直髋关节紧张短外旋肌群，在闭孔内肌和肌表面扪及坐骨神经，分离并保护好坐骨神经，自闭孔内肌与肌间隙进入，切开关节囊，显露髋臼肿瘤，肿物的根部与髋臼后壁相连，缠绕股骨颈，形态与股骨颈相适应，肿瘤上层覆盖黄白色软骨帽，纤维帽，保护好股骨头、股骨颈、关节囊及周围软组织，从根部将肿物彻底切除，小心取出肿物，肿物 ( 图 4 ) 所示：呈新月形，其形态与股骨颈相适应，质硬，大小约 4 cm×4 cm×8 cm，送病理，术中透视见肿物全部切除，并对标本进行透视( 图 5 )，与术前 X 线片对比，进一步证实此标本确为此次手术切除对象，并已切除完整。髋关节活动度好，关节稳定。生理盐水冲洗伤口，彻底止血，留置引流管 1 枚，清点敷料及器械无误后逐层关闭切口，手术顺利，术中出血量约 300 ml，术后，各足趾活动好，无麻木，术后应用抗生素预防感染，给予消肿止痛，活血化瘀等治疗。伤口定期换药，愈合后拆线，术后双髋关节正位 X 线片 ( 图 6 )示：左髋臼后壁肿瘤已切除。术后病理结果回报示：符合骨软骨瘤 ( 图 7 )。

图2 术前 CT 片：左侧髋臼后柱旁见团块状高密度影，密度不均匀，边界尚清，最大截面积约为 3.0 cm × 4.1 cm，左髋关节滑膜增厚，左髋关节内见液体密度影，病变与左髋臼后柱相连，双髋关节间隙等宽，双侧股骨头大小、形态正常，边缘光整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

图3 术前 MRI 双髋关节对称，间隙等宽，双侧股骨头大小、形态及信号正常，边缘光整，双侧髋臼关节面光滑清楚。双髋关节腔见少量长 T1长 T2信号，左髋关节滑囊内可见多个长 T1短 T2信号影，左侧滑膜明显增厚，双髋周围软组织未见明显异常信号影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

讨 论

骨软骨瘤是临床上最常见的良性骨肿瘤，约占良性骨肿瘤的 10%[1]，当骨骺骺板闭合后骨软骨瘤一般停止生长。骨软骨瘤最常发生于长管状骨的干骺端，关节外，尤以膝关节周围多见，由于肌肉的牵拉，多背向关节生长。巨大骨软骨瘤已非常少见，本例发生于髋臼后壁的单发性巨大骨软骨瘤更是非常罕见，而且张入关节内，临床上更是未见有报道，长期磨合，肿瘤与股骨头形态相适应，瘤体位于关节内，位置深在，不易触及，虽然随着肿瘤的增长会导致关节活动受限，出现跛行或者是下蹲困难。骨软骨瘤亦可生长于椎管内，好发于颈胸椎，腰椎少见，通常为孤立性，逐渐压迫马尾和神经根而出现临床症状[2]。

图4 术中大体标本：肿物呈新月形，其形态与股骨颈相适应，质硬，大小约 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

图5 术中 X 线片与术前 X 线片对比，进一步证实此标本确为此次手术切除对象，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

图6 术后 X 线片：左髋臼后壁肿瘤已切除Fig.6 Postoperative X-ray film: left acetabular posterior wall tumor had been removed

图7 术后病理结果：镜下由外至内依次为增生的纤维、软骨及骨组织，符合骨软骨瘤，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

骨软骨瘤的诊断依然是临床、影像及病理三结合。X 线片表现：位于长骨干骺端的骨软骨瘤的生长方向常于邻近肌肉牵引方向一致，本例瘤体张入关节内，与股骨头及股骨颈长期磨合，肿瘤与股骨头形态相适应。X 线片虽能诊断，但位于骨盆的肿瘤位置深在，解剖关系复杂，为明确病变的性质及其与相邻骨骼、组织的关系，必要时须行 CT 检查，以便在制订手术方案时做到心中有数[3]。CT可见肿瘤骨与正常骨髓腔相通，从而明确诊断。本例患者骨盆正位 X 线片提示骨软骨瘤或滑膜骨软骨瘤病可能，但由于显影重叠未能发现蒂部所在，因此行髋关节 CT 及三维重建进一步明确诊断及对肿瘤蒂部定位。

到目前为止手术切除是治疗骨软骨瘤的惟一方法[4]。手术指征包括[5]：压迫神经和血管导致疼痛，皮肤表面有破溃或感染，影响关节活动，压迫神经引起截瘫等；切除时应从肿瘤基底部周围部分正常骨组织开始，防止术后复发，术中将软骨帽和基质一起切除直到显露正常骨质为止[6]。对于多发骨软骨瘤，有时会围绕正常骨质一圈，为防止病理骨折，可多次切除，对于切除后的骨缺损可采取自体骨和异体骨重建[7]。本例患者左髋关节活动严重受限，临床症状明显，并且肿瘤巨大可能存在恶变，符合手术指征。髋关节的手术入路，有前侧、外侧及后外侧三种，根据瘤体的部位位于髋臼的后壁故选择左髋关节后外侧手术入路，术中保护好坐骨神经，沿髋臼后壁将肿瘤完整切除，修复关节囊及外旋肌群，关节活动度正常且关节稳定。

[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] 赵广民, 杨滔.腰椎管内骨软骨瘤二例报告.解放军医药杂志, 2014, 26(10):32-34.

[3] 李开华, 于秀淳.骨软骨瘤致骨关节畸形7例诊治分析.中国矫形外科杂志, 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] 王华宇.275例骨软骨瘤的X线影像分析.重庆医学, 2010, 39(2):235-236.

[6] 王重阳, 吴伟乾, 李明娴.股骨小转子单发巨大骨软骨瘤1例.中国骨伤, 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.

( 本文编辑：裴艳宏 李贵存 )

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，沧州中西医结合医院骨一科骨与软组织肿瘤科

张文路，Email: 84513692@qq.com

2016-08-20 )