C. A. Cipriano, D. J. McDonald , Department of Orthopedic Surgery, Washington University, St Louis, MO, USA J. Dalton , School of Medicine, Washington University School of Medicine, St Louis, MO, USA.
Clin Orthop Relat Res. 2019 Mar;477(3):584-593. doi: 10.1097/CORR.0000000000000564.
A rotational gastrocnemius flap is often used for soft tissue reconstruction after proximal tibia sarcoma resection. However, little is known about the frequency and severity of complications and the recovery of extensor function after this procedure.
QUESTIONS/PURPOSES: After gastrocnemius flap reconstruction with split-thickness skin grafting (STSG) to augment the extensor mechanism repair after proximal tibial resection for sarcoma, we asked: (1) What ROM was achieved (including extensor lag and active flexion)? (2) How often did complications and reoperations occur and what caused them?
Between 1991 and 2014, one surgeon treated 26 patients with proximal tibial resections for primary bone sarcoma. Of these, 18 were reconstructed with the preferred approach: resecting the proximal tibia leaving the patellar tendon in continuity with the tibialis anterior fascia whenever possible (10), cementing a stemmed proximal tibial endoprosthesis, suturing the patellar tendon to the implant, rotating a medial (16) or lateral (two) gastrocnemius flap over the tendon and prosthesis to augment the repair, and covering the flap with STSG. Alternative methods were used when this was technically impossible (one patient), when there was no advantage to secondary soft tissue coverage (two patients), or when the limb could not be salvaged (five patients). Of the 18 treated with gastrocnemius flaps, two were lost to followup or died of disease before the 24-month minimum and excluded; the median followup of the remaining 16 was 6 years (mean, 9.9 years; range, 2.3-21.7 years); three patients died of disease, and four have not been seen within the last 5 years. We reviewed medical records for passive and active extension, maximum flexion achieved, and complications requiring reoperation. ROM in patients with successful limb salvage was graded as excellent (flexion ≥ 110° and no lag), good (flexion 90°-110° and lag ≤ 10°), fair (one function limited: either flexion < 90° or lag > 10°), or poor (both functions limited: flexion < 90° and lag > 10°).
At latest followup, three patients had undergone amputation for deep infection. Of those remaining, median active flexion was 110° (mean, 104°; range, 60°-120°) and extensor lag was 0° (mean, 4°; range, 0°-10°). ROM was excellent in nine patients, good in three, fair in one, and poor in none. We observed 18 complications requiring reoperation in 12 patients, including deep infection (four), patellar tendon avulsion/attenuation (three), and flap necrosis (one). Survivorship free from revision or loss of the gastrocnemius flap was 74% (95% confidence interval [CI], 5.6-95.8) at 2, 5, and 10 years. Survivorship free from reoperation for any cause was 74% (95% CI, 52.0-96.0) at 2 years, 52% (95% CI, 25.8-77.8) at 5 years, and 35% (95% CI, 0-61.5) at 10 years using Kaplan-Meier analysis.
Although most patients regained functional ROM including active extension, 12 required reoperation for complications including infection and early extensor mechanism failures. Despite the observed risks, we believe the gastrocnemius flap with STSG should be considered a suitable approach to provide active extension and soft tissue coverage given the paucity of good surgical options for extensor mechanism reconstruction in this challenging clinical setting.
Level IV, therapeutic study.
旋转腓肠肌皮瓣常用于胫骨近端肉瘤切除后的软组织重建。然而，对于该手术术后的并发症发生率和严重程度以及伸肌功能的恢复情况，人们知之甚少。
问题/目的：在胫骨近端肉瘤切除后，采用腓肠肌皮瓣游离皮片移植（split-thickness skin grafting，STSG）来增强伸肌机制修复，我们提出以下问题：（1）获得的 ROM 包括伸肌滞后和主动屈曲吗？（2）并发症和再次手术的发生率是多少，是什么原因导致的？
1991 年至 2014 年，一位外科医生治疗了 26 例胫骨近端原发性骨肉瘤患者。其中 18 例采用首选方法重建：尽可能保留髌腱与胫骨前肌筋膜的连续性切除胫骨近端（10 例），骨水泥固定带柄胫骨近端假体，将髌腱缝合到植入物上，旋转内侧（16 例）或外侧（2 例）腓肠肌皮瓣覆盖在肌腱和假体上以增强修复，并使用 STSG 覆盖皮瓣。当技术上不可能（1 例患者）、二次软组织覆盖没有优势（2 例患者）或肢体无法挽救（5 例患者）时，使用替代方法。18 例采用腓肠肌皮瓣治疗的患者中，2 例失访或死于疾病，随访时间不足 24 个月，被排除在外；其余 16 例患者的中位随访时间为 6 年（平均 9.9 年；范围 2.3-21.7 年）；3 例患者死于疾病，4 例患者在过去 5 年内未就诊。我们回顾了病历，了解被动和主动伸展、最大屈曲程度以及需要再次手术的并发症。对成功保肢的患者，ROM 分级为优（屈曲≥110°且无滞后）、良（屈曲 90°-110°且滞后≤10°）、可（功能受限 1 项：屈曲<90°或滞后>10°）或差（2 项功能受限：屈曲<90°和滞后>10°）。
在末次随访时，3 例患者因深部感染行截肢。其余患者的平均主动屈曲为 104°（中位数，110°；范围，60°-120°），平均伸肌滞后为 4°（中位数，0°；范围，0°-10°）。9 例患者 ROM 为优，3 例为良，1 例为可，无差。我们观察到 12 例患者中有 18 例并发症需要再次手术，包括深部感染（4 例）、髌腱撕脱/萎缩（3 例）和皮瓣坏死（1 例）。2 年、5 年和 10 年时，不进行翻修或失去腓肠肌皮瓣的存活率分别为 74%（95%置信区间，5.6%-95.8%）、52%（95%置信区间，25.8%-77.8%）和 35%（95%置信区间，0%-61.5%）。使用 Kaplan-Meier 分析，2 年、5 年和 10 年时，所有原因导致的再次手术率分别为 74%（95%置信区间，52.0%-96.0%）、52%（95%置信区间，25.8%-77.8%）和 35%（95%置信区间，0%-61.5%）。
尽管大多数患者恢复了包括主动伸展的功能性 ROM，但仍有 12 例患者因感染和早期伸肌机制失败等并发症需要再次手术。尽管存在观察到的风险，我们仍认为腓肠肌皮瓣游离皮片移植应被视为一种合适的方法，可提供主动伸展和软组织覆盖，因为在这种具有挑战性的临床环境中，用于伸肌机制重建的良好手术选择很少。
IV 级，治疗性研究。
