右上腕悪性軟部腫瘍に対して上腕三頭筋合併切除を伴う腫瘍広範切除術を施行された症例へのリハビリテーション治療の経験

Rehabilitation Treatment after Extensive Tumor Resection Including Triceps Resection for a Malignant Right Arm Soft Tissue Tumor : A Case Report

はじめに

　四肢の悪性骨軟部腫瘍に対して，最も確実な根治治療は局所の外科的切除であり，救命あるいは局所の腫瘍コントロールによるquality of life（QOL）向上のために，可能な限りすべての症例に対して外科的な治療が検討される¹⁾．また，悪性骨軟部腫瘍の手術は，広範切除縁による腫瘍広範切除が原則とされる²⁾．手術計画・手技の進歩により，今日では四肢悪性骨腫瘍の80％以上，悪性軟部腫瘍の90％以上の症例で，初回手術として患肢温存療法が実施されるようになっている¹⁾．

　その一方で，四肢悪性骨軟部腫瘍，特に悪性軟部腫瘍の広範切除では，腫瘍の発生部位や範囲などにより，患肢の運動に重要な役割を果たす筋が合併切除の対象となる場合がある．また，それに伴い，術後の機能障害は症例により大きく異なる．そのため，骨軟部腫瘍術後に良好な機能を獲得するためには，症例に応じた適切な術後リハビリテーション治療が必要不可欠である．

　今回，右上腕悪性軟部腫瘍に対して上腕三頭筋合併切除を伴う腫瘍広範切除術を施行された症例に対するリハビリテーション治療の経験を得たので報告する．なお，本報告において，症例には書面および口頭にて十分に説明し，了承を得た．

Wide resection of malignant bone and soft tissue tumors of the extremities may require resection of muscles, which correspondingly impairs limb movements. We describe a 67-year old man with a malignant soft tissue tumor of the right upper arm. Preoperatively, there was no impairment of right upper extremity function. The patient underwent wide resection of the tumor and triceps muscle. Postoperative rehabilitation included range of motion exercises, residual muscle strength exercises, and activities of daily living (ADL) exercises. One week postoperatively, the patient could independently perform the ADL exercises. Two weeks postoperatively, the patient scored 2 during manual muscle testing (MMT) for elbow extension, indicating a complete range of motion in a gravity-eliminated position. However, the patient could not raise the arm without bending it. Considering the needs of the patient, we prescribed an elbow extension brace to support the upper limb while being raised. With this brace, the patient was able to sustain elbow extension during upper limb elevation. Three months postoperatively, the patient’s elbow joint extension remained MMT 2, grip strength was 28 kg, and the International Society of Limb Salvage and Musculoskeletal Tumor Society score was 76.7％．Although the triceps muscle was resected, there was no problem with the patient’s ADL. However, the patient could not maintain elbow extension in an anti-gravity position while raising the upper limb. In such cases, prescribing an elbow brace may be useful.