臺灣博碩士論文加值系統

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.

目錄
中文摘要………………………………………………………………………………………Ⅳ
英文摘要………………………………………………………………………………………Ⅵ
誌謝……………………………………………………………………………………………Ⅸ
目錄……………………………………………………………………………………………Ⅷ
表目錄………………………………………………………………………………………ⅩⅥ
圖目錄………………………………………………………………………………………ⅩⅦ
第一章 文獻回顧………………………………………………………………………………1
1.1簡介…………………………………………………………………………………………1
1.2大腿前外側皮瓣之分類……………………………………………………………………2
1.3股外側肌受損程度之分級…………………………………………………………………2
1.4大腿前外側皮瓣之優點……………………………………………………………………3
1.5大腿前外側皮瓣修補手術術後相關後遺症………………………………………………3
1.5.1肌肉無力……………………………………………………………………………3
1.5.2各項功能性活動表現之改變………………………………………………………5
1.5.3感覺異常……………………………………………………………………………5
1.6術後後遺症-股四頭肌無力可能造成之深遠影響：退化性膝關節炎…………………7
1.6.1股四頭肌無力與退化性膝關節炎…………………………………………………8
1.6.2股四頭肌與瞬間著地速率…………………………………………………………8
1.7總結…………………………………………………………………………………………10
1.8研究動機……………………………………………………………………………………11
1.9研究問題……………………………………………………………………………………13
1.10研究目的…………………………………………………………………………………14
1.11研究假設…………………………………………………………………………………15
第二章 研究方法………………………………………………………………………………16
2.1研究對象……………………………………………………………………………………16
2.2研究儀器與設備……………………………………………………………………………16
2.2.1手握式測力器………………………………………………………………………17
2.2.2肌電圖儀……………………………………………………………………………17
2.2.3單軸加速規…………………………………………………………………………18
2.2.4足底開關……………………………………………………………………………19
2.2.5紅外線測速器………………………………………………………………………19
2.2.6測力板………………………………………………………………………………20
2.3研究流程……………………………………………………………………………………20
2.4評估項目……………………………………………………………………………………21
2.4.1膝部功能問卷………………………………………………………………………21
2.4.2大腿周徑……………………………………………………………………………22
2.4.3下肢柔軟度…………………………………………………………………………23
2.4.4關節活動度…………………………………………………………………………24
2.4.5相關肌力測試………………………………………………………………………25
2.4.6 90-90半蹲測試……………………………………………………………………28
2.4.7慣用步態分析………………………………………………………………………29
2.5資料處理與分析……………………………………………………………………………30
2.5.1慣用步行速度………………………………………………………………………31
2.5.2瞬間最大著地速率…………………………………………………………………31
2.5.3肌電訊號分析………………………………………………………………………31
2.5.4 90-90半蹲測試測試分析…………………………………………………………34
2.6資料統計與分析……………………………………………………………………………33
第三章 研究結果………………………………………………………………………………37
3.1受試者基本資料……………………………………………………………………………37
3.2 KOOS膝功能量表分數………………………………………………………………………38
3.2.1縱向研究……………………………………………………………………………38
3.2.2橫向研究……………………………………………………………………………38
3.3大腿周徑……………………………………………………………………………………39
3.3.1縱向研究……………………………………………………………………………39
3.3.2橫向研究……………………………………………………………………………40
3.4下肢柔軟度…………………………………………………………………………………40
3.4.1髖屈肌柔軟度………………………………………………………………………40
3.4.2髂脛束柔軟度………………………………………………………………………40
3.4.3膝直肌柔軟度………………………………………………………………………41
3.5膝關節彎曲活動度…………………………………………………………………………42
3.5.1縱向研究……………………………………………………………………………42
3.5.2橫向研究……………………………………………………………………………42
3.6相關肌力測試結果…………………………………………………………………………42
3.6.1縱向研究……………………………………………………………………………43
3.6.2橫向研究……………………………………………………………………………43
3.7 90-90半蹲測試結果………………………………………………………………………43
3.7.1最長半蹲維持時間…………………………………………………………………43
3.7.2患側承重比例………………………………………………………………………45
3.8步態分析結果………………………………………………………………………………46
3.8.1慣用步行速度………………………………………………………………………46
3.8.2瞬間最大著地速率…………………………………………………………………46
3.8.3步態擺盪期中各肌肉之活化起始點………………………………………………46
第四章 討 論…………………………………………………………………………………49
4.1受試者基本資料……………………………………………………………………………49
4.2膝部功能問卷結果之比較…………………………………………………………………50
4.3大腿周徑……………………………………………………………………………………52
4.4下肢柔軟度評估結果之比較………………………………………………………………52
4.5膝關節彎曲活動度…………………………………………………………………………54
4.6相關肌力測試結果…………………………………………………………………………55
4.6.1膝直肌肌力…………………………………………………………………………55
4.6.2髖屈肌肌力…………………………………………………………………………57
4.6.3膝屈肌肌力…………………………………………………………………………58
4.6.4髖外展肌肌力………………………………………………………………………59
4.6.5髖直肌肌力…………………………………………………………………………60
4.7 90-90半蹲測試結果………………………………………………………………………60
4.7.1最長半蹲維持時間…………………………………………………………………61
4.7.2患側承重比例………………………………………………………………………62
4.8步態分析……………………………………………………………………………………62
4.8.1慣用步行速度………………………………………………………………………62
4.8.2瞬間最大著地速率…………………………………………………………………63
4.8.3各肌肉之活化起始點………………………………………………………………63
4.9術後可能之代償機制………………………………………………………………………65
4.10研究限制……………………………………………………………………………………66
4.11臨床貢獻……………………………………………………………………………………66
第五章 結 論…………………………………………………………………………………68
參考文獻…………………………………………………………………………………………70
附錄一 人體試驗委員會同意書………………………………………………………………81
附錄二 KOOS膝功能問卷………………………………………………………………………83
自述………………………………………………………………………………………………87

表目錄
表一、縱向追蹤與橫向研究之受試者基本資料與手術股外側肌損傷程度…………………38
表二、縱向追蹤與橫向研究之KOOS膝功能問卷分數…………………………………………39
表三、縱向追蹤與橫向研究中各測量高度之大腿周徑………………………………………40
表四、縱向追蹤與橫向研究中之下肢柔軟度測試結果………………………………………41
表五、縱向與橫向研究之膝關節彎曲活動度結果測量………………………………………42
表六、縱向追蹤與橫向研究中相關肌肉之平均等長收縮肌力結果…………………………44
表七、縱向追蹤與橫向研究之90-90半蹲測試結果……………………………………………45
表八、縱向追蹤與橫向研究之各項步態參數…………………………………………………47
表九、本研究與各研究報導之各肌肉活化起始點之比較……………………………………64

圖目錄
圖一、大腿前外側皮瓣血管支配型態…………………………………………………………2
圖二、microFET3手握式測力器………………………………………………………………17
圖三、肌電圖儀…………………………………………………………………………………18
圖四、單軸加速規………………………………………………………………………………18
圖五、足底開關…………………………………………………………………………………19
圖六、紅外線測速器……………………………………………………………………………19
圖七、測力板……………………………………………………………………………………20
圖八、特製皮尺合併於標有刻度之透明塑膠板………………………………………………22
圖九、湯瑪斯測試………………………………………………………………………………23
圖十、歐柏測試…………………………………………………………………………………24
圖十一、艾利氏測試……………………………………………………………………………24
圖十二、傾斜式量角器…………………………………………………………………………25
圖十三、膝直肌測試姿勢.……………………………………………………………………26
圖十四、髖屈肌測試姿勢.……………………………………………………………………26
圖十五、膝屈肌測試姿勢.……………………………………………………………………27
圖十六、髖外展肌測試姿勢……………………………………………………………………27
圖十七、髖直肌測試姿勢.……………………………………………………………………28
圖十八、90-90半蹲測試起始姿勢與測試姿勢………………………………………………28
圖十九、縱向研究：術前與術後3個月時之取皮側肌肉活化起始點………………………48
圖二十、橫向研究：術後平均14個月時之取皮側與健側肌肉活化起始點…………………48

參考文獻
(1) Anderson DD, Brown TD, Yang KH, Radin EL. A dynamic finite element analysis of impulsive loading of the extension-splinted rabbit knee. J Biomech Eng 112(2):119-28; 1990. .
(2) Arsenault AB, Winter DA, Marteniuk RG, Hayes KC. How many strides are required for the analysis of electromyographic data in gait? Scand J Rehabil Med 18(3):133-5; 1986. .
(3) Benedetti MG, Catani F, Bilotta TW, Marcacci M, Mariani E, Giannini S. Muscle activation pattern and gait biomechanics after total knee replacement. Clinical Biomechanics 18(9):871-6; 2003. .
(4) Bogey RA, Barnes LA, Perry J. Computer algorithms to characterize individual subject EMG profiles during gait. Arch Phys Med Rehabil 73(9):835-41; 1992 . .
(5) Brandt KD, Heilman DK, Slemenda C, Katz BP, Mazzuca S, Braunstein EM, Byrd D. A comparison of lower extremity muscle strength, obesity, and depression scores in elderly subjects with knee pain with and without radiographic evidence of knee osteoarthritis. J Rheumatol 27(8):1937-46; 2000. .
(6) Brandt KD, Heilman DK, Slemenda C, Katz BP, Mazzuca SA, Braunstein EM, Byrd D. Quadriceps strength in women with radiographically progressive osteoarthritis of the knee and those with stable radiographic changes. J Rheumatol 26(11):2431-7; 1999. .
(7) Bruns J, Volkmer M, Luessenhop S. Pressure distribution in the knee joint. Influence of flexion with and without ligament dissection. Arch Orthop Trauma Surg 113(4):204-9; 1994. .
(8) Bulgheroni P, Bulgheroni MV, Andrini L, Guffanti P, Giughello A. Gait patterns after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy 5(1):14-21; 1997. .
(9) Chaudhuri S, Aruin AS. The effect of shoe lifts on static and dynamic postural control in individuals with hemiparesis. Arch Phys Med Rehabil 81(11):1498-503; 2000. .
(10) Chen CM, Chen CH, Lai CS, Lin SD, Huang IY, Shieh TY. Anterolateralthigh flaps for reconstruction of head and neck defects. J Oral Maxillofac Surg 63(7):948-52; 2005. .
(11) Chen WL. Impulsive Loading in Gonarthrosis University of Oxford; 1998.
(12) Chen WL, O'Connor JJ, Radin EL. A comparison of the gaits of Chinese and Caucasian women with particular reference to their heelstrike transients. Clin Biomech (Bristol , Avon ) 18(3):207-13; 2003. .
(13) Cheng CC, Chen WL, Shieh SJ. New adaptation of measurement to improve the reliability of hand-held dynamometers used for large muscle strength tests. 5th world congress of biomechanics, Munich, German, 2006. .
(14) Cooper C, McAlindon R, Snow Sea. Mechanical and constitutional risk factors for symptomatic knee osteoarthritis: Differences between tibiofemoral and patellofemoral disease. J Rheumatol 21:307-13; 1994. .
(15) Cornwall MW, McPoil TG. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys Ther 29(12):756-60; 1999. .
(16) Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell J. Delayed onset of electromyographic activity of vastus medialis obliquus relative to vastus lateralis in subjects with patellofemoral pain syndrome. Archives of Physical Medicine & Rehabilitation 82(2):183-9; 2001. .
(17) Cram JR, Kasman GS, Holtz J. Electrode placement. Introduction to Surface Electrodmyography. 1st ed. Aspen Publishers, Inc, Maryland; p.360-9; 1998.
(18) Englund M, Roos EM, Lohmander LS. Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls. Arthritis Rheum 48(8):2178-87; 2003.
(19) Farahmand F, Naghi Tahmasbi M, Amis A. The contribution of the medial retinaculum and quadriceps muscles to patellar lateral stability--an in-vitro study. Knee 11(2):89-94; 2004. .
(20) Felson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM, et al... Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med 17;133(8):635-46; 2000. .
(21) Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW, et al.. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Public Health 84(3):351-8; 1994.
(22) Hall MC, Mockett SP, Doherty M. Relative impact of radiographic osteoarthritis and pain on quadriceps strength, proprioception, static postural sway and lower limb function. Ann Rheum Dis 65(7):865-70; 2006.
(23) Hallisey MJ, Doherty N, Bennett WF, Fulkerson JP. Anatomy of the junction of the vastus lateralis tendon and the patella. J Bone Joint Surg Am 69(4):545-9; 1987. .
(24) Hsieh CH, Kuo YR, Huang PH, Jeng SF. Free anterolateral thigh perforator flap for reconstruction of dystrophic epidermolysis bullosa-associated squamous cell carcinoma in the foot: case report. Ann Plast Surg 50(2):201-3; 2003. .
(25) Huang CH, Chen HC, Huang YL, Mardini S, Feng GM. Comparison of the radial forearm flap and the thinned anterolateral thigh cutaneous flap for reconstruction of tongue defects: an evaluation of donor-site morbidity. Plast Reconstr Surg 114(7):1704-10; 2004. .
(26) Hubley-Kozey CL, Deluzio KJ, Landry SC, McNutt JS, Stanish WD. Neuromuscular alterations during walking in persons with moderate knee osteoarthritis. J Electromyogr Kinesiol 16(4):365-78; 2005. .
(27) Hurley MV, Newham DJ. The influence of arthrogenous muscle inhibition on quadriceps rehabilitation of patients with early, unilateral osteoarthritic knees. Br J Rheumatol 32(2):127-31; 1993. .
(28) Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther 33(11):671-6; 2003. .
(29) Jefferson RJ, Radin EL, O'Connor JJ. The role of the quadriceps in controlling impulsive forces around heel strike. Proc Instn mech Engrs 204:21-8; 1990. .
(30) Kelly PA, O'Connor JJ. Transmission of rapidly applied loads through articular cartilage. Part 1: Uncracked cartilage. Proc Inst Mech Eng [H ] 210(1):27-37; 1996. .
(31) Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations and technical problems of the anterolateral thigh flap: a report of 74 cases. Plast Reconstr Surg 102(5):1517-23; 1998. .
(32) Kimata Y, Uchiyama K, Ebihara S, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterolateral thigh flap donor-site complications and morbidity. Plast Reconstr Surg 106(3):584-9; 2000. .
(33) Kimata Y, Uchiyama K, Sekido M, Sakuraba M, Iida H, Nakatsuka T, Harii K. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg 103(4):1191-7; 1999. .
(34) Kuo YR, Jeng SF, Kuo MH, Huang MN, Liu YT, Chiang YC, Yeh MC, Wei FC. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg 107(7):1766-71; 2001. .
(35) Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF. 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):149-55; 2003. .
(36) Kuo YR, Kuo MH, Lutz BS, Huang YC, Liu YT, Wu SC, Hsieh KC, Hsien CH, Jeng SF. One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata. Ann Surg 239(3):352-8; 2004. .
(37) Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW. Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 48(2):161-6; 2002. .
(38) Lewin JS, Barringer DA, AH, Gillenwater AM, Arnold KA, Roberts DB, Yu P. Functional outcomes after laryngopharyngectomy with anterolateral thigh flap reconstruction. Head Neck 28(2):142-9; 2006. .
(39) Magee DJ. Hip. Orthopedic Physical Assessment. 3rd ed. W.B. Saunders Company, Philadephia, p. 482; 1997. .
(40) Magee DJ. Hip. Orthopedic Physical Assessment. 3rd ed. W.B. Saunders Company, Philadephia, p. 483; 1997. .
(41) Marieb EN, Mallatt J. Muscles of the body. Human Anatomy. 3rd ed.
Benjamin Cummings, NY. p.312-3; 2001. .
(42) McCrory JL, Martin DF, Lowery RB, Cannon DW, Curl WW, Read HM, Jr., Hunter DM, Craven T, Messier SP. Etiologic factors associated with Achilles tendinitis in runners. Med Sci Sports Exerc 31(10):1374-81; 1999. .
(43) Mikesky AE, Meyer A, Thompson KL. Relationship between quadriceps strength and rate of loading during gait in women. J Orthop Res 18(2):171-5; 2000. .
(44) Mizner RL, Snyder-Mackler L. Altered loading during walking and sit-to-stand is affected by quadriceps weakness after total knee arthroplasty. J Orthop Res 23(5):1083-90; 2005. .
(45) Mureau MA, Posch NA, Meeuwis CA, Hofer SO. Anterolateral thigh flap reconstruction of large external facial skin defects: a follow-up study on functional and aesthetic recipient- and donor-site outcome. Plast Reconstr Surg 115(4):1077-86; 2005. .
(46) Nadollek H, Brauer S, Isles R. Outcomes after trans-tibial amputation: the relationship between quiet stance ability, strength of hip abductor muscles and gait. Physiother Res In ;7(4):203-14; 2002. .
(47) Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization. Arthritis Rheum 38(8):1134-41; 1995. .
(48) Perry J. Gait Analysis: Normal and Pathological Function. Slack Inc, Thorofare, NJ; 1992. .
(49) Radin EL, Yang KH, Riegger C, Kish VL, O'Connor JJ. Relationship between lower limb dynamics and knee joint pain. J Orthop Res 9(3):398-405; 1991. .
(50) Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self-administered outcome measure. J Orthop Sports Phys Ther 28(2):88-96; 1998. .
(51) Roos EM, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS) - validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes 25;1(1):17; 2003. .
(52) Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 105(7):2349-57; 2000. .
(53) Slemenda C, Brandt KD, Heilman DK, Mazzuca S, Braunstein EM, Katz BP, Wolinsky FD. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med 15;127(2):97-104; 1997. .
(54) Slemenda C, Heilman DK, Brandt KD, Katz BP, Mazzuca SA, Braunstein EM, Byrd D. Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women? Arthritis Rheum 41(11):1951-9; 1998. .
(55) Sokoloff L. Microcracks in the calcified layer of articular cartilage. Arch Pathol Lab Med 117(2):191-5; 1993. .
(56) 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(2):149-59; 1984.
(57) Sorosky B, Press J, Plastaras C, Rittenberg J. The practical management of Achilles tendinopathy. Clin J Sport Med 14(1):40-4; 2004. .
(58) Wolff KD, Grundmann A. The free vastus lateralis flap: an anatomic study with case reports. Plast Reconstr Surg 89(3):469-75; 1992. .
(59) Wu JZ, Herzog W, Epstein M. Joint contact mechanics in the early stages of osteoarthritis. Med Eng Phys 22(1):1-12; 2000. .
(60) Xu DC, Zhong SZ, Kong JM, Wang GY, Liu MZ, Luo LS, Gao JH. Applied anatomy of the anterolateral femoral flap. Plast Reconstr Surg 82(2):305-10; 1988. .
(61) Young A. Current issues in arthrogenous inhibition. Ann Rheum Dis 52(11):829-34; 1993. .
(62) Yu P, Lewin JS, Reece GP, Robb GL. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap. Plast Reconstr Surg 117(3):968-74; 2006. .
(63) Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study. Plast Reconstr Surg 116(7):1845-55; 2005. .