筋膜皮瓣修复四肢关节周围肿瘤术后巨大创面的应用研究

Application research of fasciocutaneous flaps in repairing large defects after tumor resection around the joints of limbs

目的分析筋膜皮瓣在四肢关节周围软组织肿瘤切除术后巨大皮肤缺损重建术中的可行性及相关并发症。方法2007年1月至2012年1月，共39例因腕、肘、髋、膝及踝等关节周围软组织恶性肿瘤在我院行病灶广泛切除及邻近部位的筋膜皮瓣转移覆盖创面术。其中男21例，女18例。患者平均年龄45．72（14～731岁。初诊10例，术后6个月内原发灶再次行扩大切除14例，术后复发15例。研究内容包括：肿瘤切除后皮肤缺损大小、筋膜皮瓣种类、术后伤口及皮瓣愈合情况、患肢外观及功能、肿瘤复发率等。结果切除肿瘤部位包括腕关节5例，肘关节3例，髋关节8例，膝关节6例，踝关节17例。采用的皮瓣包括桡动脉腕上支筋膜皮瓣5例、上臂外侧筋膜皮瓣3例、腹股沟筋膜皮瓣3例、阔筋膜张肌筋膜皮瓣3例、大腿后侧筋膜皮瓣2例、小腿后侧筋膜皮瓣6例及腓肠神经逆行筋膜皮瓣17例。所有筋膜皮瓣均可完整覆盖创面，而且血运良好。除2例发生皮缘少许坏死及1例浅表感染外，其余皮瓣均正常存活。皮瓣外观均可被患者接受，术后患肢关节活动度正常，MSTS及TESS功能评分优良。本组病例未发生大面积的皮瓣坏死及术后皮瓣严重挛缩等并发症。初诊与扩大切除及复发病例在复发率上存在显著性差异。结论筋膜皮瓣具有血供丰富、切取范围大、皮瓣弹性好及厚度适中等优点，术后皮瓣坏死及感染率低，是一类适合在关节周围软组织肿瘤切除后巨大缺损创面应用的临近皮瓣。

Objective To analyze the feasibility and related complications of fasciocutaneous flaps in the reconstruction of large skin defects after the resection of soft tissue tumors around the joints of limbs. Methods From January 2007 to January 2012, 39 patients with malignant sof~ tissue tumors around the wrist, elbow, hip, knee, ankle and so on were treated by wide resection of lesions, and fasciocutaneous flaps in the adjacent areas were transferred to cover the wound in our hospital. There were 21 males and 18 females, with an average age of 45.72 years old （ range; 14-73 years ）. Among these patients, 10 cases had primary diagnosis, 14 cases had extended resection again in primary sites within 6 months after the operation and 15 cases had tumor relapse postoperatively. The size of skin defects after tumor resection, types of fasciocutaneous flaps, postoperative healing of the wound and flaps, appearance and function of the involved joints, tumor relapse and so on were observed and recorded in all patients. Results 5 patients had tumor resection in the wrist joint, 3 in the elbow joint, 8 in the hip joint, 6 in the knee joint and 17 in the ankle joint. The adapted flaps included radial wrist upper branch fasciocutaneous flap in 5 cases, lateral upper arm fasciocutaneous flap in 3, inguinal fasciocutaneous flap in 3, broad tensor fasciocutaneous flap in 3, thigh rear fasciocutaneous flap in 2, crus rear fasciocntaneous flap in 6 and sura nervous retrograde fasciocutaneous flap in 17. All the defects were covered by fasciocutaneous flaps perfectly, with sufficient blood supply. All the fasciocutaneous flaps survived normally, except that 2 patients had light edge necrosis and 1 had superficial infections. The flaps were accepted by all patients due to their good appearance. The involved joints had normal range of motion （ ROM ） and excellent musculoskeletal tumor society score （ MSTS ） and Toronto extremity salvage score （ TESS ）. No complications such as extensive flap necrosis, serious contraction of flaps after the operation and so on were found in the patients. Significant differences existed in the recurring rate among the primary diagnosis, extended resection and relapse groups. Conclusions Fasciocutaneous flaps have the advantages such as sufficient blood supply, large area of coverage, good elastic, moderate thickness, low necrosis and infection rate of flaps postoperatively and so on, which are suitable for repairing large defects after the resection of soft tissue tumors around the joints.