肢体复合组织缺损分型的建立和临床应用

Establishment and clinical application of limb compound tissue defect classification

背景由高能量创伤或肿瘤侵犯导致的肢体一种以上组织缺损称为复合组织缺损(compound tissue defect,CTD),是骨科和创伤外科临床中最为棘手的情况之一。对于复合组织缺损的类型和严重程度目前无统一的评估标准。目的提出一种新的复合组织缺损分型方式,为复合组织规范化修复重建提供依据。方法本研究团队根据既往研究和临床经验建立了基于软组织(soft tissue defect,S)、骨(bone defect,B)、神经缺损(nerve defect,N)不同组织类型和严重程度的肢体复合组织缺损分型(limb compound tissue defect classification,LCTDC),具体分为3大类8个亚型(3大类为LCTDCⅠ、Ⅱ、Ⅲ型,8个亚型为ⅠA、ⅠB、ⅠC、ⅡA、ⅡB、ⅡC、ⅢA、ⅢB型)。纳入解放军总医院第四医学中心骨科医学部2019年6月-2021年12月复合组织缺损患者175例,由两组医师(A组为6名骨科主治医师,B组为2名骨科主任医师)根据术前缺损部位专科检查及影像资料进行LCTDC分型,并确定亚型和制定手术计划,以B组结果为金标准,对A组的评价结果进行一致性检验。结果175例复合组织缺损患者,其中男性113例,女性62例,平均年龄28.3岁。四肢骨与软组织巨大肿瘤113例,四肢高能量损伤清创术后伴复合组织缺损62例。B组两名主任医师评估后LCTDC分型:Ⅰ型40例,Ⅱ型79例、Ⅲ型56例。两组医生LCTDC总分型一致性评估的Kappa值为0.783(P<0.05);各亚型(包括手术计划的制定)结果的一致性检验Kappa值为0.671~0.821(P均<0.05)。结论年轻医生和有经验的骨科医生在术前对患者进行LCTDC分型和确定亚型及手术方案时一致性较高,本研究所建立的LCTDC能够帮助医生准确评估伤情并选择合理的重建方式,有利于规范和优化手术策略。

Background Compound tissue defect(CTD),caused by high-energy trauma or tumor invasion,is one of the most difficult conditions in clinical practice,and there is no unified evaluation standard for the classification and severity of CTD.Objective To propose a new classification method for the normalized reconstruction of compound tissue.Methods According to previous research and clinical experience,our team established a limb compound tissue defect classification(LCTDC)system based on the type and degree of soft tissue defect(S),bone defect(B)and nerve defect(N).The compound tissue defects were divided into 3 categories(LCTDCⅠ,Ⅱ,Ⅲ)and 8 subtypes(ⅠA,ⅠB,ⅠC,ⅡA,ⅡB,ⅡC,ⅢA,ⅢB).Totally 175 patients with limb tumor or CTD caused by high-energy injury who underwent multi-compartment resection in the Department of Orthopedics of our hospital from June 2019 to December 2021 were included.According to the preoperative examinations and imaging data,two groups of orthopedists(including 6 attending orthopedists in group A and 2 chief orthopedists in group B)performed assessment to tissue defects based on LCTDC system,and made surgical plans.Kappa consistency test was performed on the evaluation results of doctors in group A using the results of group B as the gold standard.Results Of the 175 CTD patients,there were 113 males and 62 females,with an average age of 28.3 years.There were 113 cases with large bone and soft tissue tumors in limbs,and 62 cases with complex tissue defects after high energy trauma of limbs.The LCTDC types assessed by two chief orthopedists in group B were as follows:40 cases of typeⅠ,79 cases of typeⅡ,56 cases of typeⅢ,The Kappa coefficient of consistency assessment on the general LCTDC classification was 0.783(P<0.05),and the Kappa coefficient on the subtypes(including the development of surgical plan)ranged from 0.671 to 0.821(all P<0.05).Conclusion There is a high consistency in the results of CTD classification and subtype determination between the experienced and young orthopedists.The LCTDC established in this study can guide orthopedists to perform preoperative injury assessment and select a reasonable reconstruction method for patients,which is beneficial to standardize and optimize the surgical strategy and improve the success rate of surgery.