胫骨近端肿瘤型人工假体保肢治疗中肌瓣的作用

Effect of muscle flap in limb salvage operation of tumor type prosthesis of proximal tibia

背景:胫骨近端肿瘤型假体置换后易出现局部假体外露、感染等并发症。通过转移腓肠肌内侧肌瓣覆盖胫骨假体表面,可有效降低术后并发症发生风险,但在长节段胫骨近端人工假体置换中单纯应用腓肠肌肌瓣转移覆盖胫骨假体面积有限,需要联合其他修复方式进行重建。目的:观察应用腓肠肌、比目鱼肌肌瓣转移修复胫骨假体置换后软组织缺损的临床效果。方法:纳入中国医科大学附属盛京医院于2017年3月至2020年6月收治的胫骨近端恶性骨肿瘤患者17例,对所有肿瘤均行瘤段切除,肿瘤型人工膝关节假体置换手术治疗。当胫骨假体长度与腓肠肌肌瓣最大宽度差≤腓肠肌肌瓣最大宽度时,单独应用腓肠肌内侧头肌瓣转移即可重建胫前软组织缺损;当胫骨假体长度与腓肠肌肌瓣最大宽度差大于腓肠肌肌瓣最大宽度时,应用腓肠肌内侧头肌瓣联合比目鱼肌肌瓣覆盖胫骨假体。术后定期随访患者,下肢功能通过国际骨与软组织肿瘤协会评分系统评价。结果与结论:①17例患者均获随访,平均随访(17.5±9.8)个月;②全部患者伤口均Ⅰ期愈合,无感染和皮瓣坏死并发症,其中1例骨肉瘤患者行膝关节假体置换后1年因化疗后假体周围感染行截肢治疗,未见肿瘤假体翻修、肿瘤转移及死亡病例;③患者国际骨与软组织肿瘤协会评分平均24分,其中优10例,良2例,可5例,膝关节屈曲角度为(84.76±12.88)°;④上述数据证实,在行胫骨近端肿瘤型人工假体保肢治疗中,患者可根据胫骨假体长度与腓肠肌肌瓣最大宽度差选择腓肠肌、比目鱼肌肌瓣转移修复软组织缺损,可无张力、充分地覆盖假体表面,有效减少局部并发症。

BACKGROUND:The prosthesis replacement with tumors of the proximal tibia will lead to complications such as local prosthesis exposure and infection.The transfer of the medial gastrocnemius muscle flap to cover the surface of the tibial prosthesis can effectively reduce the risk of postoperative complications.However,in the replacement of the long-segment proximal tibia prosthesis,the transfer of the gastrocnemius muscle flap to cover the tibia is only used.The area of the prosthesis is limited,and it needs to be reconstructed with other repair methods.OBJECTIVE:To investigate the clinical effect of applying gastrocnemius muscle flap and soleus muscle flap to repair the soft tissue defect after tibial prosthesis replacement.METHODS:From March 2017 to June 2020,17 patients with proximal tibia malignant bone tumor admitted to the Shengjing Hospital of China Medical University.All tumors were treated by tumor segment resection and tumor knee prosthesis replacement.The medial gastrocnemius muscle flap alone was used to reconstruct the anterior tibial soft tissue defect,when the difference between the length of the tibia prosthesis and the maximum width of the gastrocnemius muscle flap was less than or equal to the maximum width of the gastrocnemius muscle flap.The medial gastrocnemius muscle flap combined with the soleus muscle flap could effectively cover the tibial prosthesis without tension,when the difference between the length of the tibia prosthesis and the maximum width of the gastrocnemius muscle flap was greater than the maximum width of the gastrocnemius muscle flap.Patients were followed up regularly after surgery,and lower limb function was evaluated by the Musculoskeletal Tumor Society scoring system.RESULTS AND CONCLUSION:(1)All 17 patients were followed up,with a mean of(17.5±9.8)months.(2)The incisions were healing by first intention in all patients without infection,skin flap necrosis and other complications.One patient with osteosarcoma underwent amputation due to periprosthesis infection after chemotherapy one year after knee prosthesis replacement,and there was no case of revision of tumor prosthesis,metastasis or death.(3)Musculoskeletal tumor society score was averagely 24 points,of which 10 cases were excellent,2 cases were good and 5 cases were fair.The knee flexion angle was(84.76±12.88)°.(4)Above data confirmed that during limb salvage treatment of tumor prosthesis of proximal tibia,gastrocnemius muscle flap and soleus muscle flap were selected to repair soft tissue defects according to the difference between the length of tibia prosthesis and the maximum width of gastrocnemius muscle flap,which could fully cover the prosthesis surface without tension and effectively reduce local complications.