目的 探讨带蒂皮瓣修复四肢大关节周围恶性软组织肿瘤切除后软组织缺损的临床疗效.方法 回顾性分析于2012年6月至2017年6月治疗的四肢大关节周围恶性软组织肿瘤,切除后应用带蒂筋膜皮瓣或带蒂肌皮瓣转移修复软组织缺损103例.男61例,女42例;平均年龄52.3(14～82)岁.初诊32例,外院术后二次扩大切除30例,术后复发再手术41例.肿瘤位于腕关节周围13例:应用桡动脉腕上支筋膜皮瓣、尺动脉腕上皮支皮瓣、前臂骨间后动脉逆行皮瓣修复;肘关节周围8例:应用臂外侧皮瓣、臂内侧皮瓣修复;肩关节周围8例:应用背阔肌皮瓣、侧胸壁皮瓣修复;髋关节周围14例:应用股直肌皮瓣、股后筋膜皮瓣、阔筋膜张肌皮瓣修复;膝关节周围16例:应用小腿前外侧皮瓣、小腿后侧皮瓣修复;踝关节周围44例:应用隐神经大隐静脉营养血管皮瓣、腓肠神经小隐静脉营养血管皮瓣、外踝上皮瓣、足底内侧皮瓣修复.肿瘤切除后皮肤缺损面积3 cm×4 cm～18 cm×25 cm.观察记录术后皮瓣情况、并发症、关节活动度及肿瘤复发转移情况.结果 术后除6例发生部分或全部坏死外,其余皮瓣均成活,成活率94.2％.坏死病例改用其他皮瓣或游离皮片移植修复.感染4例:供区2例,受区2例,经换药及抗生素治疗二期愈合.12例失访,剩余91例随访1～5年,平均33个月,所有皮瓣外形、质地好,不臃肿,无水泡.顺行筋膜皮瓣及肌皮瓣的浅感觉正常,逆行筋膜皮瓣恢复保护性感觉.患侧关节活动度术后6、12个月随访较健侧无明显差异,肢体功能良好.臀骶部、足跟等负重区皮瓣未发生溃疡,坐姿与步态正常.肿瘤复发17例,远处转移32例,死亡21例.初诊、二次扩大切除与复发再切除病例的术后肿瘤复发率分别为10.3％、11.5％和30.6％,差异存在统计学意义(P<0.05).结论 应用带蒂皮瓣修复四肢大关节周围恶性软组织肿瘤切除后软组织缺损,手术方法简单方便,安全可靠,疗效满意,值得推广.%Objective To investigate the clinical effect of using pedicled flap to reconstruct skin and soft tis-sue defect after resection of sarcoma around extremities joint. Methods Retrospectively analysis 103 cases of sar-coma around extremities joint who was treated from June, 2012 to June, 2017 and used the pedicled fasciocutaneous flaps or pedicled musculocutaneous flaps to reconstruct the defect after sarcoma resection. There were 61 males and 42 females, with a mean age of 52.3 (14-82 ) years old. Among these patients, there were 32 initial diagnosis, 30 had been resected in other units, and 41 recurrent tumor. There were 13 patients that tumor around wrist:reconstructed by radial wrist upper branch fasciocutaneous flap, dorso-ulnar flap based on supracarpal perforator, and posterior in-terosseous artery flap. Eight patients with tumor around elbow: reconstructed by lateral arm flap and media arm flap. Eight patients with tumor around shoulder: reconstructed by latissimus dorsi musculocutaneous flap and lateral tho-racic flap. Fourteen patients with tumor around hip: rectus femoris musculocutaneous flap, tensor fascia lata musculo-cutaneous flap, and posterior thigh fasciocutaneous flap. Sixteen patients that tumor around knee:reconstructed by an-terolateral low leg flap, and sural calf fasciocutaneous flap. Forty-four patients that tumor around ankle: reconstructed by saphenous neuro-veno-fasciocutaneous flap, sural neuro-veno-fasciocutaneous flap, lateral supramalleolar flap, and medial plantar flap. The defect area after tumor resection were:3 cm ×4 cm-18 cm×25 cm. After surgery, observe the situation and fitness of flap, complication, joint mobility, and tumor recurrence and metastasis. Results Allflaps survived except 6 died or partial died, with a survival rate of 94.2％, of which dead flap were replaced by a new flap or covered by free skin graft. Infection occurred in 4 cases (2 in donor site and 2 in recipient site), were cured by dressing and antibiotic. Except for 12 cases dropped, all rest 91 cases were followed-up by 33 months on average (1-5 years), flaps' shape and texture were good, without swollen and fester, and fit well. Superficial sensibility of direct fasciocuta-neous flaps and musculocutaneous flaps were normal, protective sensation of reverse fascial flaps were recovered. The mobility of affected joint show no difference compared with the other side. No ulcer occurred on flaps of plantar and but-tocks, that helps normal sit position and gait. There were 17 recurrences and 32 metastasis occurred, 21 patients died so far. There was a statistical difference between recurrent cases with first shot(10.3％) second widely resection(11.5％) and recurrent resection(30.6％)(P<0.05). Conclusion Using pedicled flap to reconstruct skin defect after the resection of sarcoma around extremities joint, can get good clinical result, with simple and reliable operation. It is worth to popularize.
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