摘要
研究背景與目的：大腿前外側皮瓣(Anterolateral thigh flap)手術已被廣泛運用於整形重建上。此術主要牽涉股外側肌(Vastus lateralis)，亦即人體膝直肌群中之最大肌肉，於日常生活中扮演穩定膝關節之重要角色。然而至今卻鮮有研究針對大腿前外側皮瓣重建手術之後遺症進行客觀評估，相關問題輪廓仍然不明，更遑論因此類後遺症造成之深遠影響及其衍生之問題。本研究目的在針對接受大腿前外側皮瓣重建手術之病患，進行客觀量化之評估，包含KOOS膝功能問卷、大腿周徑、下肢柔軟度、相關肌力評估、膝直肌肌耐力檢測、患側承重比例評估，及步態分析（慣用步行速度、最大瞬間著地速率與膝部肌肉於步態擺盪期之動作控制策略），來了解此手術對於骨骼肌肉系統可能造成之後遺症與代償機制，以利未來治療計畫之設計。研究方法：本研究包含兩實驗設計，分別於縱向研究中，徵召8位將接受大腿前外側皮瓣重建手術之病患，於術前、術後三和六個月時針對取皮瓣側進行評估比較。另外於橫向研究中，徵召術後6個月以上之患者共11名，進行術後相關評估，直接比較取皮瓣側與健側之差異。由於受試者流失率高，完成術前術後測試之人數尤其是撐到術後六個月者非常有限，故統計方面乃採取魏氏帶符號試驗檢定縱向研究中取皮瓣側於術前與術後3個月間之差異，以及橫向研究中取皮瓣側與健側間之差異。結果：於縱向研究中發現大腿前外側皮瓣重建手術患者於術後三個月時在KOOS膝功能量表（尤其是日常生活活動、運動與休閒活動與生活品質等面向）、取皮瓣側髕骨上方15公分處之大腿周徑、取皮瓣側股直肌柔軟度、取皮瓣側各肌群之肌力、膝直肌肌耐力、以及患側承重比例等方面，均較術前呈現顯著差異(p<0.05)。其中運動與休閒活動與生活品質兩面向分數、取皮瓣側髖屈肌、髖外展肌與膝直肌之肌肉力量、患側承重比例與取皮瓣側股直肌柔軟度等項目，於術後六個月時仍然呈現不如術前的現象。此外步態中肌電訊號分析結果顯示，股直肌於步態擺盪期之活化起始點相較於術前反而有顯著提早的現象(p<0.05)。而在橫向研究中，取皮瓣側髖屈肌、髖外展肌與膝直肌之肌力以及患側承重比例均顯著低於健側(p<0.05)；而且病患於取皮瓣側相較於健側顯著呈現股直肌柔軟度不足之現象(p<0.05)；此外步態分析結果亦顯示，取皮瓣側股內斜肌於步態擺盪期之活化起始點反而較健側顯著提早(p<0.05)。結論：本研究為首次針對大腿前外側皮瓣重建手術之後遺症，提出全方位測量與分析之研究。本研究除改善過去研究之缺失外，並設計多項新的評估方法，發現許多過去未注意到之術後變化，此外又觀察患者於術後之步態控制策略已經改變，會自行利用股直肌或股內斜肌於著地前之擺盪期提早收縮，也許因而免於最大瞬間著地速率之提高。本研究之結果，不僅可提供相關手術於術後評估與治療計畫訂定之參考，亦提供間接證據支持大腿前外側皮瓣重建手術患者於術後步態控制策略之改變，或有助於緩解罹患退化性膝關節炎之隱憂。

Abstract
Background and Purpose. The anterolateral thigh (ALT) flap had been developed for widespread clinical applications. The vastus lateralis muscle could be sacrificed during the dissection process of ALT flap, however it was the largest compartment of the quadriceps femoris muscle and might play an important role on the stability of the knee joint in daily living. To date only few studies have provided objective assessments for the postoperative donor-side complications of ALT flap reconstructive surgery, in which weakness of knee extensors was the main focus reported. There may be more sequels requiring further attention. The purpose of this study was to set up systemic assessments for evaluating the sequels for ALT flap reconstructive surgery, including the Knee injury and Osteoarthritis Outcome Score (KOOS), thigh circumferences, lower extremity flexibility, related muscle strength, endurance of the knee extensors, weight bearing pattern and gait analysis (walking speed, peak loading rate at heel strike transients, muscle activation pattern before heel strike). Methods. Two study designs (follow-up and cross-sectional design) were conducted in this study. In the follow-up design, 8 patients having ALT flap reconstructive surgery were recruited to participate evaluation before and at 3 months and 6 months after surgery. In the cross-sectional design, 11 ALT flap patients were recruited to participate postoperative evaluation only for both the donor legs and the healthy legs at more than six months after surgery. Due to the high drop-out rate at 6 month after surgery, several Wilcoxon’s signed-rank tests were conducted simply to examine the differences between pre-operative assessments and the assessments 3 month after surgery. In the cross-sectional design, the Wilcoxon’s signed-rank tests were used to examine differences in the assessments between donor legs and healthy legs. Results. Subscales of the KOOS (function in daily living, function in sport and recreation and knee related quality of life), thigh circumference at 15 cm above patella, the rectus femoris flexibility, all related muscle strength (knee extensors, hip flexors, hip abductors, knee flexors, and hip extensors), knee extensor endurance, and weight bearing percentage were significantly lower at 3 months after surgery in the donor legs compared to pre-operative status (p<0.05). There was still a decrease in function in sport and recreation and knee related quality of life, the rectus femoris flexibility, related muscle strength (knee extensors, hip flexors, hip abductors), and weight bearing percentage in the donor legs even at 6 month after surgery. In addition, significantly earlier activation of the rectus femoris before heel strike in the donor legs were found at 3 month after surgery (p<0.05). Further, the results of our cross-sectional study also showed that the donor legs exhibited significantly weaker knee extensors, hip flexors, and hip abductors, limited rectus femoris flexibility, and decreased weight bearing percentage than the healthy legs even at the time later than 6 months after surgery (p<0.05). At this time, activation of the vastus medialis in the swing phase of gait cycle before heel strike also showed significantly earlier onset in the donor legs than in the healthy legs (p<0.05). Conclusions. In present study we have demonstrated significantly decreased knee function (especially in subscales of function for sports and recreation, and knee related quality of life), significant weakness in hip flexors, hip abductors, and knee extensors, significantly limited rectus femoris flexibility, and significantly reduced weight bearing percentage in the donor legs during squatting in patients after ALT flap reconstructive surgery. We also found unchanged walking speed and peak loading rate at heelstrike transients accompanying with apparent gait alterations such as significantly earlier activation of rectus femoris and vastus medialis in the swing phase of gait cycle. Obviously a compensatory mechanism for the control strategies of gait pattern has been developed after ALT flap reconstructive surgery, and might have contributed to the reduction of impact at heelstrike transients. The findings of the present study have provided thorough understanding to the sequels of ALT flap and might help to suggest more efficient rehabilitation interventions after ALT flap reconstructive surgery. In addition, circumferential evidence has been proposed in the present study to show the possibility of reduced risk for gonarthrisis after ALT flap reconstructive surgery by altering gait control strategies in daily walking pattern.

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