膝部惡性腫瘤切除後以大腿前外側皮膚及筋膜複合式自由皮瓣重建膝關節伸展功能之病例報告

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1 台灣癌症醫誌 (J. Cancer Res. Pract.) 26(), 37-42, 200 Case Report journal homepage: One-Stage Reconstruction of Extensor Mechanism with Free Composite Anterolateral Thigh Flap and Vascularized Fascia Lata after Malignant Tumor Resection of Knee Tsung-Sheng Ni, Shih-Hsin Chang *, Ter-Yang Huang 2, Hung-Tao Hsiao, Kwang-Yi Tung Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan 2 Department of Orthopaedic Surgery, Mackay Memorial Hospital, Taipei, Taiwan Abstract. Background: Combined loss of the extensor apparatus with overlying soft tissue at the level of the knee joint is a difficult challenge to the reconstructive surgeon. Traditionally, it can be achieved with staged operations. However, multiple-stage reconstructions are time-consuming and costly, and the results are usually not satisfactory. Objectives: These patients need not only soft-tissue coverage for the defects but also functional recovery of the knee joint. The composite free anterolateral thigh (ALT) flap can provide soft-tissue coverage and vascularized fascia lata for tendon reconstruction. Methods: We report on a patient with a composite skin and knee extensor mechanism defect after an ablative surgery for malignancy treated by an anterolateral thigh (ALT) flap incorporated with vascularized fascia lata for reconstruction of the patellar tendon defect. Results: One year after the operation, there was no extensor lag at the knee, with knee flexion of 95. This patient is able to walk without support. Conclusions: This one-stage surgical procedure simultaneously provides excellent functional tendon reconstruction and adequate soft-tissue coverage. 病例報告 Keywords : extensor mechanism, free anterolateral thigh flap, vascularized fascia graft TAO 膝部惡性腫瘤切除後以大腿前外側皮膚及筋膜複合式自由皮瓣重建膝關節伸展功能之病例報告 倪宗聖 張世幸 * 黃德揚 2 蕭弘道 董光義 台北馬偕紀念醫院整形外科 2 台北馬偕紀念醫院骨科 中文摘要背景 : 膝關節軟組織合併伸展功能缺損的功能重建, 對於整形外科醫生常常是一種挑戰 傳統上, 需要多階段的手術來完成重建 但是多階段的手術既耗時又耗醫療費, 結果也常常不是非常令人滿意 目標 : 這些病患不僅需要軟組織重建, 並且需要重建膝關節的功能 使用大腿前外側皮膚及筋膜複合式自由皮瓣, 來同時作軟組織及肌腱的重建

2 38 T. S. Ni et al./jcrp 26(200) 材料與方式 : 我們報告一例膝關節惡性腫瘤經廣泛切除後軟組織及伸展機能缺損, 以大腿前外側皮膚及筋膜複合式自由皮瓣來做軟組織及髕骨肌腱的重建 結果 : 經過一年的追蹤, 病患膝關節的伸展功能沒有明顯的缺損, 膝關節的彎曲可達 95 度 病患可不用柺杖自行行走 結論 : 使用大腿前外側皮膚及筋膜複合式皮瓣, 對同時重建肌腱及軟組織, 得到非常良好的功能重建 關鍵字 : 伸展機能重建 大腿前外側自由皮瓣 帶血管筋膜移植 INTRODUCTION Combined loss of the patellar tendon and overlying soft tissue of knee joints remains a great challenge for reconstructive surgeons as both require reconstruction. Traditionally, this can be achieved with staged operations, using local muscle flap or cutaneous flap for coverage first [-3], followed by different allografts, synthetic grafts, and autologous tendon grafts to restore the continuity and function of the patellar tendon. These multiple-stage reconstructions are timeconsuming and costly, and the results are usually not satisfactory [4-6]. The composite free anterolateral thigh (ALT) flap can provide not only skin flap for soft-tissue coverage but also vascularized fascia lata for patellar tendon reconstruction in one stage. We report on a case using such an approach. CASE REPORT A 62-year-old man with a painless, gradually enlarging prepatellar tendon tumor mass of his right knee for several months received intralesional excision of the tumor mass in another hospital. The initial pathologic diagnosis was malignant giant cell tumor of the patellar tendon. The tumor mass in the right knee recurred and progressively grew 2 months postoperatively (Figure A). The patient was therefore *Corresponding author: Shih-Hsin Chang M.D. * 通訊作者 : 張世幸醫師 Tel: Fax: prschang@yahoo.com.tw referred to our hospital for further evaluation and management. The magnetic resonance imaging of the right knee revealed a lobulated tumor mass arising from the anteroinferior patellar space involving the extensor mechanism (Figure B). Bone scan showed no abnormality in the skeleton. Radical resection of the tumorous tissue, including the patellar tendon, the lower two thirds of the patella, tibial tuberosity and partial knee joint capsule, was performed by an orthopaedic surgeon, and histopathological examination of the lesion revealed malignant fibrous histiocytoma. Tumor resection resulted in an 8x6-cm soft- tissue defect and a 0-cm tendon defect (Figure C). An ALT flap incorporated with vascularized fascia lata was designed for reconstruction. After a cutaneous perforator was located by Doppler audiometry, a 22x8-cm ALT flap was elevated together with a 2x2-cm tensor fascia lata strip (Figure 2A). The fascial sheet was then rolled into a tendon-like structure, and fixed to the remnants of the patella and tibial tuberosity with proper TAO tension with the knee in full extension. The anterior tibial vessels served as the recipient pedicle, and the vascular anastomoses were performed under a microscope. Then the soft tissue defect was fully covered with the skin flap (Figure 2B). The donor site defect was laid down with split thickness skin graft. Postoperatively, the patient also received radiation therapy. Physiotherapy was started 6 weeks postoperatively and ambulation training started 4 weeks later. At 4-month follow-up, the patient had good function recovery, with an active extension deficit of 0 and an active flexion of 45, and was able to return to

3 T. S. Ni et al./jcrp 26(200) Figure A. Preoperative view of the tumor. Extension 39 Figure B. Magnetic resonance imaging scan shows a of the tumor has been marked on the skin large low- density mass in the right knee involving the patellar tendon mount importance for preservation of the function of the knee joint. Numerous procedures, including crossleg flaps [7], saphenous flaps [4], reversed flow saphenous island flaps [], transposition gastrocnemius flaps [2,3], sartorius muscle or musculocutaneous flaps [5,6], vastus medialis muscle flaps [8], distally based vastus lateralis muscle flaps [9], popliteo-posterior thigh fasciocutaneous island flaps [0], peroneal island flaps [] or free flaps [2], have been utilized to provide coverage, but surgeons were not able to reconstruct the missing patella tendon with vascularfigure C. Immediate view after resection of malig- ized tissue in one stage. nant fibrous histiocytoma In the past, those defects necessitated multipletao staged operations and a long period of rehabilitation, and they usually resulted in inadequate functional rehis job. At one- year follow-up, the patient regained covery as tendons were reconstructed with non-vas- 95 active knee flexion without extension lag (Figure cularized tissue including allografts, synthetic grafts, 3A,B). The patient can now walk normally. or autologous tissues. Furthermore, these reconstructed tendons needed reinforcement at the second stage. DISCUSSION Ideally, patellar tendon and coverage defects can be Malignant fibrous histiocytoma is the most com- reconstructed in one stage with a single vascularized mon soft tissue sarcoma in adults, but it rarely devel- composite tissue, and the newly reconstructed tissue ops as a primary tumor in the patellar tendon. Recon- should be strong enough and possess gliding capabil- struction of defects around the knee after tumor resec- ity. tion is a challenge. Early aseptic closure is of para- Several types of free microvascular tissue trans-

4 40 T. S. Ni et al./jcrp 26(200) Figure 2A. an 22x8cm composite anterolateral thigh flap including a 2x2cm of fascia lata Figure 2B. Then the fascial sheet was fixed to the remnants of the patella and tibial tuberosity with the knee in full extension. Then the soft tissue defect is fully covered with the skin flap A B Figure 3. At one- year follow- up, the patient had regained 95 active knee flexion without extension lag T A O plantations have been proposed for simultaneous re- nism of a knee joint, the reconstruction often needs a construction of the Achilles tendon with the corre- large area of skin and fascia grafts. The composite sponding soft tissue, including radial forearm flap radial forearm flap, brachioradialis flap and lateral with palmaris longus tendon graft [3], brachioradialis arm flap lack adequate volume. The tensor fascia lata with flexor carpi radialis tendon [4], lateral arm flap muscle flap has a bulky muscle component, needs an- with triceps tendon graft [5,6], groin flap with ex- other skin graft and is difficult to apply in reconstruc- ternal oblique aponeurosis [7,8], latissimus dorsi, tion. The main pedicle of the groin flap is relatively tensor fascia lata muscle with its fascia lata graft [9], short and flimsy, and the excessive amount of fat pos- and musculotendinous gracilis flap [20]. For cases es another problematic issue when incorporating the with combined loss of the skin and extensor mecha- external oblique fascia. Moreover, synthetic materials

5 T. S. Ni et al./jcrp 26(200) (Marlex mesh) may sometimes be needed to repair the secondary fascial defect. With the latissimus dorsi, the final wound coverage involves a large sheet of split thickness skin graft, so the durability, pliability and gliding capability of the skin envelopes may be of concern. The free ALT flap was first described by Song et al in 984 [2], and it has been widely used to reconstruct various types of defects, including those in the head and neck region, abdominal wall and extremities. The advantages of using this flap are multifold. The use of a free ALT composite flap with fascia lata for reconstruction of a posterior heel composite defect has been reported [22,23], with satisfactory results in all patients without postoperative ambulating difficulties. However, for reconstruction of prepatellar skin and patellar tendon defects, few cases have been reported. Our patient made an uneventful and rapid recovery, which was instrumental in prompting an early return to the rehabilitation program that helped to prevent further wasting of the calf muscle. The main advantages of this operation are that it is a single- stage procedure and provides effective tendon reconstruction and satisfactory skin coverage. Donor site morbidity, although objectively existent, is mild and does not interfere with daily activities. The free ALT flap with vascularized fascia lata has been shown to achieve acceptable knee power strength and range of motion in composite patellar tendon reconstruction. This combined method simultaneously enables reconstruction of the patellar tendon and provides adequate soft- tissue coverage. Physiologic healing with well-vascularized tissue allows prompt physiotherapy. Thus, the functional results achieved with this method are promising. This report indicates that the composite free ALT flap is a useful option in the reconstruction of compound defects of the knee. REFERENCES. Tsai CC, Lin SD, Lai CS, et al. Reconstruction of the upper leg and knee with a reversed flow saphenous island flap based on the medial inferior genicular artery. Ann Plast Surg 35: 480-4, Elsahy NI. Cover of the exposed knee joint by the lateral head of the gastrocnemius. Br J Plast Surg 3: 36-7, Feldman JJ, Cohen BE, May JW Jr. The medial gastrocnemius myocutaneous flap. Plast Reconstr Surg 6: 53-9, Acland RD, Schusterman M, Godina M, et al. The saphenous neurovascular free flap. Plast Reconstr Surg 67: , Petty CT, Hogue RJ Jr. Closure of an exposed knee joint by use of a sartorius muscle flap: case report. Plast Reconstr Surg 62: 458-6, Hong JP, Lee HB, Chung YK, et al. Coverage of difficult wounds around the knee joint with prefabricated, distally based sartorious muscle flaps. Ann Plast Surg 50: , Barclay TL, Sharpe DT, Chisholm EM. Cross-leg fasciocutaneous flaps. Plast Reconstr Surg 72: 843-7, Arnold PG, Prunes-Carrillo F. Vastus medialis muscle flap for functional closure of the exposed knee joint. Plast Reconstr Surg 68: 69-72, Swartz WM, Ramasastry SS, McGill JR, et al. Distally based vastus lateralis muscle flap for coverage of wounds about the knee. Plast Reconstr Surg 80: , 987. TAO 0. Maruyama Y, Iwahira Y. Popliteo-posterior thigh fasciocutaneous island flap for closure around the knee. Br J Plast Surg 42: 40-3, Yoshikata R, Yanai A, Tsuzuki K, et al. Transinterosseous transfer of a peroneal island flap for reconstruction of prepatellar skin defect: report of two patients. Ann Plast Surg 29: 80-5, Serafin D, Sabatier RE, Morris RI, et al. Reconstruction of lower extremity with vascularized composite tissue: improved tissue survival and specific indications. Plast Reconstr Surg 66: 230-4, Isenberg JS, Fusi S. Immediate tendon Achilles

6 42 T. S. Ni et al./jcrp 26(200) reconstruction with composite palmaris longus grafts. Ann Plast Surg 34: 209-2, Cavanagh S, Pho RWH, Kour AK. A composite neuro-teno-cutaneous forearm flap in the onestage reconstruction of a large defect of the soft tissue around the ankle. J Reconstr Microsurg 7: , Sylaidis P, Fatah MFT. A composite lateral arm flap for the secondary repair of a multiply ruptured Achilles tendon. Plast Reconstr Surg 96: , Berthe JV, Toussaint D, Coessens BC. One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap. Plast Reconstr Surg 02: , Wei FC, Chen HC, Chuang CC, et al. Reconstruction of Achilles tendon and calcaneus defects with skin-aponeurosis-bone composite free tissue from the groin region. Plast Reconstr Surg 8: , Jeng SF. Free composite groin flap and vascularized external oblique aponeurosis for traumatic avulsion injuries of the foot. J Trauma 35: 7-74, Deiler S, Pfadenhauer A, Widmann J, et al. Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia. Plast Reconstr Surg 06: , Feibel RJ, Jackson RL, Lineaweaver WC, et al. Management of chronic Achilles tendon infection with musculotendinous gracilis interposition freeflap coverage. J Reconstr Microsurg 9: , Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 37: 49-59, Lee JW, Yu JC, Shieh SJ, et al. Reconstruction of the Achilles tendon and overlying soft tissue using antero-lateral thigh free flap. Br J Plast Surg 53: 574-7, Kuo YR, Kuo MH, Chou WC, et al. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: clinical experience and functional assessment. Ann Plast Surg 50(2): 49-55, TAO