Y HOC VIET NAM THANG 2 - SO 1/2014
KET QUA PHAU THUAT NOI SOI DIEU TRI BONG DIEM BAM DAY CHANG CHEO TRU-OC KHOT GOI
T O M TAT
Tir thang 1/2011-6/2013, tai Benh vien Viet Dire, chiing toi da phau thuat noi soi eo dmh 36 trpdng hpp bong (Jiem bam day chang cheo tru'dc khdp gdi. Muc tieu: Danh gia ket qua dieu tn bong diem bam DCCT khdp gdi bang phau thuat npi soi, Doi tu'dng va phu'dng phap nghien cu'u: 35 benh nhan bong diem bam DCCT diTi^c co dmh lai diem bam bang chi thep hoac chi khong tieu bang ky thuat noi soi. Ket qua nghien cu'u: 88,9% tru'dng hpp manh xUPng ve dung vi tri giai phau, 100% lien xUPng, theo IKDC eo 87,1%
rat tdt va tot, 9,7% trung binh va 3,2% xau, theo thang diem Lysholm ty le rat tot va tdt chiem 80,6%, trung binh 16,1% va kem 3,2%. Ket Iuan: Phau thuat npi soi co dmh diem bam DCCT khdp goi eho ket qua kha quan, an toan va hieu qua.
Tit khoa: ndi soi khdp goi, bong diem bam, day ehSng cheo tru'dc,
S U M M A R Y
RESULTS OF ARTHROSCOPIC TREATMENT OF AN AMLSION FRACTURE THE TILIAL EMINENCE Objectives: Evaluate the results of arthroscopic reduction and fixation of an avulsion fracture of the tibial eminence in Viet Due University Hospital, Subjects and Methods: 36 patients who had avulsion fracture of the tibial eminence were arthroscopically fixed by tension band wire technique.
Results: 88,9% were good anatomical reduction, 100% obtained healing, according to scoring system of Lysholm, 80,6% patients rated as excellent and good, 16,1% fair and 3,2% poor. Conclusion: The arthroscopic tension band wire technique showed good and efficacious results.
Afeiworrfff; arthroscopy, ACL avulsion fracture,
I.
OJ^T VAN O I^ Khdp gdi la mot trong nhu'ng khdp chiu li/c ehinh ciia c6 the. Trong cac thanh phan dam bao sir viJng chac ciia khdp gdi, day chang cheo tru'dc (DCCT) cd vai t r d quan trong, chdng lai sir tru'dt ra tru'dc va xoay trong eiia xu'dng chay so vdi xu'dng diii. Bong diem bam DCCT khdp gdi la mdt trong ba dang dirt DCCT (DCCT cd the bi nho ra khdi nguyen iiy d xu'dng diii, cd the bj dirt
*Benh vien VietD&c
Phan bi$n khoa hgc: PGS. TS Ngo Van Toin
Nguyen Manh Khanh*
d phan than eua day chang hoac bj bong ra khoi diem bam tan d xu'dng chay).
Di/a vao mdc dp di lech eiia manh xu'dng diem bam DCCT tai mam chay, Meyer va Mc Keever phan thanh cae dp I, I I , IIIA va IIIB, OJ the nhir sau:
- Dp I ; manh xu'dng bong khdng di lech hoae di lech rat it
- Dp I I : manh xu'dng bong di lech t i r 1/2-1/3 dp day khdi vi t r i d mam chay
- Dp I I I : gom 2 loai
-I- Dp IHA; manh xu'dng bong hoan toan khoi mam chay
+ Do I I I B : manh xu'dng bong bat ngu'de len tren be mat dien gai chay
Sau nay, Zaricznyj cung chia thanh 4 loai, trong dd 3 loai dau tu'dng ttr nhtr phan loai eua Meyer va Mc Keever nhu'ng them dp IV (hay cdn gpi la dp IIIc) la manh xu'dng di lech nhieu va eo nhieu manh nhd [1,2].
Hinh 1. Phan loai bong diem bam DCCT theo Meyer- Mc Keever, cd bo sung ciia Zaricznyj [2]
J u I ' iflA ' ' l i n n ! ' \ K ,
Da sd cac tac gia tren the gidi deu thong nhat rang vdi nhu'ng tru'dng hdp bong diem bam DCCT khdng hoac it di lech (dp I theo phan loai Meyer va Mc Keever) thi cd the dieu tn bao ton bang each chpe hut mau tu khdp goi va bat dpng bdt dm goi. Vdi nhu'ng tru'dng hdp bong diem bam DCCT di lech (do I I , III) thi nen phau thuat de ed dinh lai manh xu'dng bong. Tru'dc kia, cac phu'dng phap phau thuat kinh dien deu phai mcl khdp de ed djnh lai nhu'ng cd nhieu nhu'dc diem nhu" han che c<3 nang, nguy cd nhiem triing khdp gdi... Hien nay, ciing vdi sir phat trien ky thu?t va phu'dng tien dung cu, phau thuat npi soi ta li/a chpn hang d^u de phau thuat co djnh lai bong
'7^
Y HOC VIET NAM THANG 2 - SO 1/2014
diem bam DCCT vdi nhiJng u'u diem vu'dt trdi nhu it xam lan, danh gia du'Oc toan bd eac ton thu'dng, riit ngan thdi gian dieu tri... Tai Viet Nam da cd mdt sd ft cac bao cao va thu du'dc ket qua rat kha quan. Xuat phat tir thirc te nhiT vay, chiing tdi thirc hien nghien cdu "Ket qua phau thuat noi soi dieu trj bong diem bam day chang cheo tru'dc khdp goi", nham danh gia ket qua dieu tri bong diem bam DCCT khdp gdi bang phau thuat ndi sol.
IL OOI TUONG VA PHU'OTMG PHAP NGHIEN CLTU 2 . 1 . Odi tu'dng nghien cu'u
Gdm 36 benh nhan (8 nam, 28 niT), dd tuoi trung binh 29,9±10,9 (18-50 tudi), bi bong diem bam DCCT khdp gdi do I I , I I I theo Meyer- Me Keever va dd I I , I I I , IV theo Zaricznyj tai Benh vien Viet Dire tir thang 1/2011 den thang 6/2013.'
2.2. Phu'dng phap nghien cii'u Vo cam gay te tiiy sdng. Tu' the: benh nhan nam ngira, ehan phau thuat de tren ban md. Npi soi kiem tra khdp, hiit sach dich va mau tu, bdm rira sach d khdp. XiS tri cae ton thu'dng kem theo (neu cd) nhu" rach sun chem, lay bd di vat sun khdp... Lam sach giu'dng eiia manh xu'dng bi bong, dat lai manh xu'dng bong diing vi tri, trong tru'dng hdp can thiet ed the co dinh tam thdi bang kim Kirschner 1,4 hoac 1,6 mm.
Hinh 2. Hinh anh ndi soi tru'dc va sau khi eo dinh tam thdi diem bam DCCT_
Dung thu'dc dinh hiTdng dirdng ham xu'Ong chay dat dau dinh vi vao manh xu'dng bong, hu'dng di tir mat tru'dc trong xu'dng chay den diem bam DCCT vdi gdc do la 55°. Khoan du'dng ham thir nhat qua manh xu'Ong bong vdi dp I I va IIIA hoac ben canh gdc DCCT vdi dp IIIB, sau do luon kim ed lo da dat san ehi chd. Tiep tue thu'c hien du'dng ham thir hai tu'dng t i / nhiT tren. Tir du'dng vao phia trong khdp gdi diing dung cu ludn chi thep hoae chi khdng tieu Endo qua goc day chang (vi tri giu'a 2/3 trirdc va 1/3 sau eiia gdc DCCT). Ludn hai dau spi chi qua chi chd keo xudng hai du'dng ham chay ra ngoai, Sau khi kiem tra lai manh xu'dng bong da ve giai phau eo dinh chi d thanh xu'dng chay. Bdm rifa, hut sach 0 khdp goi, khau da va cd dinh bang nep 6m gdi tu' the dudi.
Hinh 3. Hinh anh ndi soi tru'dc va sau khi cd djnh diem bam DCCT bang chi khdng tieu
Y Hpc VIET NAM THANG 2 - SO 1/2014
Tap luyen sau mo: tap trong nep trong 2
tuan dau, tap di lai, ty de mdt phan tir tuan thd 2, tap gap gdi tang din 0-120'^ tir tuan thir 3-8, tap sire manh cua cd td dau diii, ed Hamstrings...tang dan theo thdi gian, di lai vdi nang trd 66 tir tuan 8-12, sau 3 thang tap chay nhe tai chd. Bat dau chdi the thao trd lai tir thang thir 6-9.
Danh gia ket qua: Chung tdi danh gia chirc nang theo bang danh gia ciia Hpi khdp gdi qudc te IKDC (1993) va theo thang diem ciia Lysholm:
rat tdt > 90 diem, tdt 84-90 diem, trung binh 65- 83 diem, xau < 65 diem. Ket qua lien xu'dng du'dc danh gia diTa tren lam sang va X quang theo thang diem ciia Lleberman: lien xu'dng khi cd hinh anh can xu'dng dp 4 va 5.
III. KET QUA VA BAN LUAN
Chiing tdi da phau thuat 36 tru'dng hdp, cd 24 benh nhan do tai nan giao thdng, 8 tai nan sinh hoat, 3 do chan thu'dng the thao va 1 benh nhan do tai nan lao dpng. Cd 20 ca khdp gdi trai va 16 khdp gdi phai.
Thdi diem phlu thuat: tir khi bj chan thu'dng den khi phau thuat chii yeu du'di 1 tuan (22 ea), tir 1-4 tuan cd 8 ca va sau 4 tuan cd 6 ca. Nhiing tru'dng hdp den mudn chii yeu da diTdc dieu trj bao tdn hoac d tuyen du'di chuyen den do khdng cd dieu kien phau thuat. Chung tdi cung nhat trf vdi cac tac gia trong va ngoai ndde la vdi bong diem bam DCCT thi nen phau thuat sdm eang sdm cang tdt. Theo Cooper dlem bam DCCT ve mat vi the du'dc chia thanh bdn vimg: viing 1 (day chang hoan toan), viing 2 (xd sun), viing 3 (xd sun giau chat khoang) va viing 4 (xu'dng xop hoan toan).
Cac viing nay lien ket rat vitng chac vdi nhau, bong diem bam DCCT la d phan xu'dng, khi benh nhan den mudn mau cue va to chiTc xd sdi lap vao dien gay se anh hu'dng tdi qua trinh lien xu'dng [3]. Do vay, khi phau thuat cung can lam sach dien gay tru'dc khi eo dmh dien bam DCCT.
Phan loai mire do ton thu'dng va chf dinh phau thuat: tat ea eac benh nhan deu du'dc danh gia mirc dp tdn thu'dng dda tren phlm X quang theo phan loai eiia Meyer- Mc Keever
Bang 1, Phan loai mdc do ton thu'dng (n=36)
Do ton thu'dng
I II IIIA IIIB
So lu'fJng 0 6 18 12
Ty le % 0 16,7 52,8 30,6 ThUdng tdn chii yeu la dp IIIA chiem 52,8%,
ke den la dp IIIB va do I I . Theo mgt sd tae gia nhu' Meyer- Mc Keever, Zaricznyj thi bong dlem bam DCCT dp I, II dieu trj bao tdn bd bdt trong vong 6 tuan va chup X quang trong qua trinh dieu tri de kiem tra di lech thir phat, vdi dp IIIA, IIIB thi dieu trj phau thuat co djnh lai diem bam.
Mpt so tac gia nhu' Kobayashi, Le Hanh thi cho rang nen phau thuat co djnh lai diem bam DCCT ca vdi do I va II de du'a benh nhan trd lai cupc sdng sinh hoat sdm nhat [4,5], Chung tdi nhan thay qua hinh anh X quang cung nhu' danh gia ndi soi trong mo thi ranh gidi de phan loai ton thu'dng dp II va IIIA la rat gan nhau. Vdi dp II chi can tac dpng nhe cung cd the trd thanh dp IIIA. Vi vay, chiing tdi cho rang nen phau thuat cho nhu'ng tru'dng hdp cd tdn thu'dng d mire do II trd len theo phan loai ciia Meyer- Mc Keever.
Trong 36 benh nhan cd 5 tru'dng hdp cd ton thu'dng kem theo: 3 benh nhan rach sun chem
trong, 1 benh nhan dung dap DCCT va 1 benh nhan ton thu'dng mat sun Idi cau trong xu'dng dill. Mpt so tac gia nhan xet thay tinh dpc lap ciia tdn thu'dng bong diem bam DCCT. Mac dii vay, van nen chup cdng hu'dng tir de tranh bd sdt cac thu'dng tdn kem theo, nhat la nhu'ng tru'dng hdp dieu tri bao ton bong diem bam DCCT dp I.
Ky thuat cd dmh diem bam DCCT: Chung toi
ed djnh diem bam DCCT vdi chi thep cho 10
tru'dng hdp, chi Endo cho 26 tru'dng hdp. Thdi
gian dau chiing tdi cd djnh chii yeu bang chi thep
sd 0 hoac so 1 nhu'ng nhan thay thao tac se kho
khan hdn vi sdi chi kha eirng. Neu sir dung chi
thep lua hoac chi thep nha khoa thi khdng dam
bao chiu lu'c, do vay, chiing toi chuyen sang co
djnh bang chi Endo khdng tieu, sdl chi dii mem
mai khi khau npi soi nhu'ng van dam bao do vOtig
chac. Vdi nhu'ng tru'dng hdp do I I , manh xu'dng
bong cd kich thu'dc kha to nen cd the khau xuyen
qua manh xu'dng. Nhu'ng tru'dng hdp do IIIA,
Y HOC VI$T NAM THANG 2 - SO 1/2014
IIIB manh xu'dng thu'dng khdng nguyen ven hoac gay thanh nhieu manh nhd nen chung tdi phdi hdp khoan d ben canh manh xu'dng va khau ehi xuyen qua gdc day chang bat cheo thanh hinh sd 8 roi mdi keo chi ra ngoai de buoc, nhu" vay se giup cd dinh manh xu'dng vii'ng chac hdn.
Sau phau thuat khdng cd benh nhan nao bj nhiem khuan khdp, tu mau trong khdp hay n h i l m triing vet md, Kiem tra X quang sau mo cd 32/36 tru'dng hdp (88,9%) manh xu'dng bong dirdc cd djnh dimg v; trf giai phau, ed 4 trUdng hdp chu'a dat yeu cau deu la do IIIB.
Bang 2. Danh gia ket qua theo Lysholm (n=31) K e t q u a
Rat tot Tot Trung binh
Xau
S o l U t f n q 9 16
5 1
T y le »/o 29 51,6 16,1 3,2
Chtjng toi theo doi xa sau 6 thang d&dc 31 benh nhan, theo thang diem Lysholm ty le rit tot va tot chiem 80,6%, trung binh 16,1% va kem 3,2%. Tit ca cac benh nhan deu lien xddng, trong do 5/31 can xudng do 4 va 26/31 can xddng dp 5.
Bang 3. Danh gia ket qua theo IKDC va mire do tdn thu'dng (n=31) Ket qua | P Q l I | PoIHA | Oo IIIB | Tvle°/o
Tdt Trung binh
1
38,7
9,7
77/eo TKDC (1993), ty le rit tot va tot chiem 87,1 %, trung binh 9,7% va xiu 3,2%. Kit qua cua chung toi cung t&dng td nhd cua cac tac gia Meyers, Aderinto...[l,6]. Nhdng tr&dng hdp ton th&dng dp I!
deu cho ket qua rit tot va tot, tdn th&dng dp IIIB co 1 benh nhan kit qua xiu, nguyen nhan chu yeu do ngddi benh tap phuc hoi chdc nang khong theo hddng dan, sd dau nen bi dinh khdp gdi va da d&dc phau thuat npi sol lam van dpng khdp.
IV. K ^ LUiBkN
Qua nghien cdu 36 tru'dng hdp bong diem bam day chSng cheo tru'dc khdp gdi du'dc phau thuat npi soi ed dinh lai dlem bam eho thay ket qua rat kha quan vdi 8 8 , 9 % manh xu'dng ve dung vj tri giai phau, 100% lien xu'dng, theo IKDC cd 8 7 , 1 % rat tdt va tdt, 9,7% trung binh va 3,2% xau, theo thang dlem Lysholm ty le rat tdt v^ tdt chiem 80,6%, trung binh 1 6 , 1 % va kem_
3,2%. Npi soi khdp cd nhieu u'u diem, vet md nhd, It dau, giup ngu'di benh nhanh chdng lay lai v$n dong va cliirc nang khdp gdi, can tiep tyc d i n h gia vdi so lu'dng benh nhan Idn hdn va thdi gian theo ddi xa hdn.
TAI UEU T H A M KHAO
1. Mc Keever FM, Meyers MH (1970), "Fracture of the intercondylar eminence of the tibia", JBJS (Br), 52(8), pp 1677-1684,
2. Zaricznyj B (1977), "Avulsion fracture of the tibial eminence. Treatment by open reduction an pinning", JBJS (Br), 59(8), pp 1111-1114, 3. Misol S, Cooper RR (1970), 'Tendon and
ligament insertion", JBJS (Br), 52, pp 1-20.
4. Le Hanh (2005), "Danh gia ket qua dieu tr; bong diem bam DCCT khdp goi bang ky thuat npi soi", Luan van thac sy y khoa.
5. Kobayashi S, Terayama K (1994), "Arthroscopic reduction and fixation of a completely displaced fracture of the intercondylar eminence of the tibia", Arthroscopy, 22(2), pp 49-56.
6. Aderinto J, Walmsley P, Keating 3F (2008), Fracture of the tibial spine: epidemiology and outcome". Knee, 15(3), pp 164-167.
