TAP CHi NGHIEWCyU Y H O C •
PHAU THUAT CHUYEN PHAN CHEO CO RONG TRONG LEN B a TREN XU'QNG BANH CHE OIEU TR!
SAI KHO'P XU'QNG BANH CHE TRE EM
Nguy§n Ngoc Htpng Benh vien Nhi Tmng wcmg Nghien cwu nham danh gia kit qua lam sang va chirc nang sau phiu thuat didu tn sai kh&p xuong banti che do xo hoa co tir dau o tre em Nghidn ciru hdi ciru tir thing 3 nam 2004 ^dn thang 12 nam 2010 Co 65 benh nhi (69 kh&p gdi) cd sai khop xuong banh chd sau tidm khang sinh nhidu lin trong co tir diu diii Co 14 tre trai (21.5%) va 51 tre gai (78.5%) Tudi trung binh tai th&i diem phiu thuat 7 tudi 2 thing. Phan toai sai khop xwong banh che theo Bensahel Bdnh nhan dwoc chuydn phin cheo co rdng trong len bo tren xuung binh che Khong cd kdt qua kem hoac tai phat sat khop sau mo Han chd gip gdi trong 6 goi (8.7%), mit dudi 5 - 20° trong 6 gdi (8,7%,). Nhin chung, chung tdi thu duvc kit qua Rit tdt 47 gdi (68,1%). Tdt 18 gdi (23,2%), Kha 6 gdi (8.7%). Kit luan irong sai kh&p xwffng banh che tre em doxahda co tir diu sau tiem khang sinh, phau thuat chuyen phan cheo co rdng trong len bo tren xwong binh chd cho kit qua phuc hdi CO chi dudi gdi. Ky thuat don gian, an toan va cd hieu qua vol xwong chwa trw&ng thanh o tre em.
TCr khoa: xwong banh che khong vung; sai kh6p xu-cng banh che, tao hinh co- tii' d l u , ban sai kho'p XLTCcng banh che, loan san t i l n tri4n xu^o-ng banh che (DDP)
I. OAT VAN DE
Sai khdp xu'ang banh che la mdt benh chinh hinh thu'dng gap d tre em, Benh do nhilu nguyen nhan gay nen nhu- Idng day chlng, hdi chirng Down, cirng dinh khdp nhilu nai b i m sinh, hoac sau c h i n thirang vung khdp gdi, eo eirng p h l n mem me ngoai khdp gdi, genu valgum, genu reeurvatum, xu'ang banh che d vi tri cao, loan san xu'ang banh che, xu'ang dui xoay trirdc, x o l n xuang c h l y ra ngoai [1]
G i n day, mdt nguyen nhan da duae mdt sd tac gia nhu' Sharrard 1979 [2], William 1980 [3], Alvarez 1980 [4], Mukherjee 1980 [5], Dennis 1993 [6], Hung 2008 [7] cho r i n g sai Dia chi hen he Nguyen Ngoc Hung, benh vien Nhi Trung irong
email ngocyenhung@gmail com Ngaynhan. 10/11/2013 Ngay <3uuc chap thuan 28/4/2014
khdp xirang banh che d tre em do xa hda co tir d l u dui sau tiem khang sinh Cho tdi nay da cd n h i l u ky thuat p h l u thuat khac nhau cho sai khdp banh che Cotta 1959 [8] diem lai y van t h l gidi da ed 137 ky thuat phlu thuat eho benh ly nay Song, cho tdi nay chu'a cd kjf thuat p h l u thuat neng cho sai khdp xuang banh che a tre em do xa hda ea lir d l u i3ui sau tiem khang sinh trong ca
C h i n doan nguyen nhan sai khdp xuang banh che Ire em edn nhieu tranh luan, ky thuat p h l u thuat chu'a du'ae thdng n h l t Do do, de tai nghien ci>u n h l m muc lieu
Xac dmh nguyen nhan, iam sang va chan doan hinh anh eua khdp gdi cd sai khdp xu'ang banh che
Danh gia k i t qua p h l u thuat chuyen phan cheo ca rdng trong Ien b d tren xu'ang banh ehe d i l u tr| sai khdp xirang banh che
TCNCYH 87 (2)' 2014
• TAP CHl N G H I S N CCPU Y HOC
II. 061 TU'gNG VA PHU'aNG PHAP
1.D6i tu'O'ng
061 lu'p'ng trong nghien ciru nay bao gdm 65 b^nh nhan (69 gdi), du'p'c p h l u thuat tir nam 2004 d i n nSm 2010. Tuoi dirac p h i u thuat tir 6 - 1 5 luoi
B$nh nhi cd tiem khang sinh trong ca dui (nhu: penicillin, gentamycine, lineomycin, streptomycin, cloxaeiiin ), khdng ed t i l n sir chan thaang, hogc trin sir gia dinh cd sai khdp xaang banh che
Banh nhan du'p'c Ipai trir khoi nghien ciru B^nh nhan da dirac p h l u thuat sai khdp xirang banh che, cd e h i n thu'ang khdp gdi, banh ly b i m smh k i t hp'p
2. Phu-cng p h a p : hdi c d u . md la Lam sang
• xac dmh trat khdp xu'ang banh che ra ngoai, vao trong
- Gdc g i p goi khi cd trat xirang banh ehe (giu xuang banh che trong vi tri giai phlu)
- Do chu VI dCii tren bd tren xirang banh ch6 10 cm
- Day va daa xirang banh che vao trong vdi goi g i p 30"
- x a c d m h gde Q [ 1 ] . Chan doan hinh anh
- X quang xu'ang banh che alta thu'c hien theo Isall-Salvati Index 1971
Xu'ang banh ch6 nghieng ngoai theo ky thuat cua Launn va cdng sir 1978
- Cpng hwang tu- (MRI) Xac dmh ranh xirang banh che ndng, theo ky thuat cua Seil va cdng sy 2000,
- BSng. bet ldi cau ngoai xwong din (CT Scan) theo danh gia va phan loai cua Dejour vacOngsu'1990
- Xo hOa CO tr6n si^u Sm (ultrasound) Sieu am 1/3 du'di, mat ngoai dui
Phan loai sai lihop xipomg banh che Benh nhan du'oc phan loai theo lieu chuin cua Bensahel va cdng sa [9]
Type 1: Sai khdp xaang banh che khdng cd b i t thadng Idn xirang khdp tren X quang.
Type 2 Sai khdp xuang banh che vdi loan san banh che-dui, xaang banh che alta, b l n g bet Idi c l u ngoai xu-ang diii
Phau thyat:
Raeh da Rach da mat trude ngoai diii dai 12 cm, tdi cac tren ngoai xirang banh che va eong theo bd ngoai xu'ang banh che tdl ldi cu trade xaang c h l y Tach da theo sat can dui.
bde Id ca tir d l u diii, bao khdp gdi ca hai me trong va ngoai, dai chau c h l y C l t sat bam tan cua gan co rdng ngoai sat xaang banh che, tach rdi gan nay theo sat gan ea t h i n g diii v l trung tam khoang 8 cm, c l t bam tan phan cheo ca rdng trong sat bao khdp me trong, tach v l trung tam tai vach lien ca cua p h l n cheo va p h l n t h i n g cua ca rdng trong
Phuang phap t i l n hanh theo 3 bade Bu'dc thu nhat, tao hinh bao khdp.
Rach bao khdp ngoai theo doc mep ngoai xaang banh che dai khoang 8 cm (ehu y khdng iam ton thaong bao khdp) Rach bao khdp me trong each bd trong xuang banh che 2 cm, tach dadi mep bao khdp va tao vat bao khdp Day xaang banh ehe v l vi tri giai p h l u va gdi g i p 60^ Khau chdng vat bao khdp trong b l n g eh! Ethibond 2/0
Bade thd hai lam dai ca t u dau diii Tien hanh tach rdi hai gan t h i n g diii va rdng gida, c l t gan ca rdng gida each xaang banh che 6 em Bade tiep theo cho g i p gdi, tuy mdc dd gdi g i p thac hien theo hai ky thuat sau
Neu gdi gap duoc tren 90 dd, c l t va loai bd manh gan ea rdng giCra dai 4 cm, khau co dmh p h l n ea edn iai ciia ca rpng giira vao vdi
TCNCYH 87 (2)-2014
TAP CHi NGHIEN C l f U Y HOC
ea t h i n g diii. Dat goi g i p 60 do, khau ca rdng ngoai vdl bd ngoai eua co t h i n g din (VI).
N l u gdi khdng qua 90 dd, e l t gan c a t h i n g diJi each bd xaang banh che 2 cm. Kiem tra xaang banh ehe trong khi d l goi g i p tdi da v l n tran traat tren ranh lien ldi c l u d l dang;
t i l n hanh khau hai gan t h i n g diii va rdng giira vdi gdi d vi tri g i p 60 dd (V2).
Bade thir ba: ehuyin phan cheo ca rdng trong (VMO) tdi b d tren xaang banh che
Khdp gdi trong vj tri gap 60°, dwa mep dudi ngoai cua VMO ldi eac tren ngoai xaang banh che, mep dadi trong eua VMO tdi cac tren trong xaang banh che; p h l n edn lai eua VMO len bd tren xaang banh ehe, khau cd dinh b l n g chi Ethibond 2/0
Kiem tra e l m mau ky, ddng v l t md vdi khau hai Idp dadi da va da b l n g chl Vicryl 3/0 Chi daae b i t ddng b l n g bdt hai vd, vdi gdi g i p 60 dd
Ngay thir ba sau md, benh nhan b i t dau tap van ddng tren nguyen t i c p h l u thuat vien la ngudi tap van dpng trong tuan dau lien sau phau ihuat Tuan tiep theo phdi hap giCra cha me benh nhan va Bac sT vat ly tn lieu Tap nhe nhang vdi gdi g i p khdng qua 90 dd trpng 3 t u l n dau, va nhirng t u l n t i l p sau tang d i n 10 dd /tuan cho tdi khi dat g i p gdi ldi da
Benh nhan daae kiem tra dmh ky sau mo 3 t u l n , 6 t u l n , 3 thang, 6 thang, 1 nam va mdi nam 1 ian cho nhirng nam sau nay
Tieu chuan danh gia ket qua Danh gia k i t qua theo d i l m chirc nang khdp gdi cua Fuikerson 1990 va Kujala 1993
R l t tdt 90 - 100 diem, Tdt 80 - 89 d i l m , Kha' 70 - 79 diem, Kem < 70 diem
3. Dao dLKC t r p n g nghien ctru P h l u thuat duae sa ddng thuan eua Cha me benh nhan Nghien ciru da d a a e thdng qua "Hdi ddng dap ddc trong Y hoc" cua Benh vien K i t qua sau p h i u thuat chirc
nang khdp gdi phyc hoi i l l , khong cd tai biln trong va sau md.
III. K^T QUA
Cd 14 trai (21,5%) va 51 gai (78,5%). Tuoi trung binh tai thdi d i l m mo 7 tuoi 2 thang {6 tuoi 7 thang tdi 12 tudi 6 thang).
Gdi phai 28 (43,1%) va gdi trai 33 (50,7%), 4 benh nhan bi ea hai ben (6,2%).
Cd 4 gdi (5,8%) sai khdp xaang banh che ra ngoai trong mpi thdi gian; 65 gdi (94,2%) co sai khdp x a a n g banh che khi gdi g i p ,
X a a n g banh che giif a v\ tri giai phlu, hgn c h l g i p gdi 10 - 20" trong 36 gdi (52,2%), han c h l g i p gdi 30° trong 29 gdi (42,0%), 4 goi (5,8%) x a a n g banh che lien tuc n i m ngoSi dui. N l u xaang banh che trat khdp ra ngoai, khdp gdi cd t h l g l p .
Cd 4 benh nhan cd cdng khdp gdi doi di?n, 4 benh nhan khae cd eirng khdp sau tiem khang smh (1 benh nhan khdp khuyu do xo ca tam dau canh tay, 3 benh nhan ed giang vai do xo CO Delta)
Phan loai sai kh&p xu^ng banh che Type 1 48 gdi (69,6%), Type 2: 21 g6i (30,4%)
Trung binh gdc Q trade md 14,8° (13,6 "•
21,7 °) Co 4 goi ed goc Q > 20°. Sau mo, gbc Q trung btnh 8,2°(p < 0,001)
Tat ea benh nhan cd dui teo do tinh trgng ca t d d l u xa hda Cd 25 gdi cd diii teo nho
< 1,5 cm, daae p h l u thuat theo V I , Co 44 g6i cdn lai, dill teo nhd tir 1,5 - 2,5 cm duac phlu thuat theo V2 Sau mo, phue hdi rd vdi p < 0,001
Do xa hda bao khdp ngoai nen khdng c6 kha nang daa x a a n g banh che vao trcng ovi tri gdi g i p 30° Sau mo, t i t ca xaang banh che cd the d i y traat vao trpng > 5 cm vdi g i g i p 30 ° (bang 1)
TCNCYH 87 (2)-2014
• TAP CHi NGHIEN CCPU Y HOC Bang 1. Lam sang t r y d ^ m6 va tai thd'i diem danh gia k i t qua p h l u thuat
Trieu chu-ng Tru-ac md '
Bui teo nhd 69(100%) Xi/ang banh che triiot vao trong zmno/
< 5 mm vol goi gap 30° °' GocQ 14,8° (13,6-21,7°)
li thcri diem danh gia i<dt qua
8 (14,3%) 0 8,2° (6° - 13,1°)
P 0,001
0,001
Bang 2, C h i n doan X quang
Diu hieu Tru'dc m6
Xifang banh che aita 14 (20,3%) XtFong bSnh che nghieng ngoai 36 (52,2%) Ranh banh che - diii nong 17 (24,6%) Bing bet l6i c i u ngoai x y o n g dui 12 (17,4%)
K i t qua sau cung 3 (4,3%) 3 (6,4%) 2 (2,9%) 4 (5,8%)
p
>0,01
< 0,001
< 0,001
>0,01
Trudc mo, xaang banh che alta trong 14 gdi (20,3%), sau md ehi cdn t h l y trong 3 gdi (4,3%) Trirdc mo, xaang banh ehe nghieng ngoai trong 36 gdi (52,2%), sau mo chi thly 3 gdi (4,3%) (p < 0,001), Trade mo ranh banh che - diii ndng trong 17 goi, 12 goi cd b l n g bet ldi e i u ngoai xuang din Sau md, chi cdn t h l y 2 gdi cd ndng ranh banh che - diii ndng va 4 gdi edn b l n g bet ldi clu ngoai xaang dii\
Tdn thu-o-ng trong md
Trong mo, ca rgng ngoai xa hda rd, eo cirng vS n g l n trong t i t ca benh nhan Mdt b i t thudng thay rd dai chau c h l y bam vao mat trudc va ngoai xaang tren xaang banh che va phln dadi ea rdng ngoai trong t i t ea benh nhan (100%) Bao khdp ngoai d l y va xa hda Co cirng ca t h i n g dui trong 41 gdi (59,4%), va co rdng gida 28 gdi (40,6%) P h l n cheo ca rOng trong cang trong 61 goi (88,4%) VMO thoai hda va trd nen t h i n g anh hadng trac tiep tdi ehde nang kdo xaong banh che vao trong cua VMO
Trong md, chiing tdi thay rd xa hda ca rdng ngoai, rdng giaa, va bao khdp ngoai Tinh trang thoai hda ca rdng trpng, ea t h i n g dill Tinh trang co xa hda duac thly taang ta vdl xa hda co tu d l u , ea tam d l u , ca mdng va CO Deltoid sau tiem khang smh trong ca a tre em
Xac dmh tinh trang xa hoa cua ca lien quan tdi chdc nang cua ea bi ton thaang, lien quan tdi phuang phap p h l u thuat (VI hoae V2)
TCNCYH 87 (2)-2014
TJDIP CHi NGHIEN CU'U Y HOC
Bang 3. Co cfrng chinh, co cii-ng k i t ho-p, lien quan v a i ky thuat p h l u thuat va chiPC nang kho-p g6i
Ky Co ciKng chinh Co cuing thuat
k i t h a p p h l u
ChiPC nang kho-p goi sau phau thuat
Han che gap Mat duoi
Rong ngoai n = 28 Rong ngoai n = 41
Rong giu'a Rong giLi'a va t h i n g Siii
thuat
V I
V2 60°
(2 - < 9 0 °
0
2
2 ,9%)
>9D°
2
2
4 (5,8%)
< 10°
0
2
2 (2,9%)
> 1 0 ° - < 2 0 °
0
4
4 (5,8%)
>20°
0
0
0
Sau md, t i t ca benh nhan cd xaang banh ehe nam trong ranh banh che - dui khi gdi gapvS d u l l . Chirc nang khdp gdi trd v l binh thadng trong 57 gdi (82,6%), Han c h l g i p gdi 60 - 90°
trong 2 gdi (2,9%), va > 90° trong 4 gdi (5,8%), va khdng ed m l t dudi > 20°, M l t dudi x l y ra chi khi ca rdng giira va t h i n g dui ciing cd ton thuang nang (thudng p h l u thuat theo V2)
Tai thdi diem danh gia sau cimg, thdi gian trung binh sau mo 5 nam 6 thang (tCr 2 nam 4 thang tdi 9 nam 8 thang) Tudi trung binh benh nhan 11 tuoi 3 thang (tir 9 tudi 2 thang tdi 16 tuoi 4 thang)
Bang 4. Tudi benh nhan tai thd'i diem k i l m tra sau md va diem Kujala
Tuoi benh nhan
> 9 - < 11 (n = 30)
> 1 1 - < 14 (n = 37)
> 14 (n = 2)
T6ng'c6ng R i t t6t
22 (46,8%)
24 (51,1%)
1 (2 1%)
47 (68,1%)
Ket qua sau mo Tot
4 (25,0%)
11 (68,8%)
1 (6,2%)
16 (23,2%)
Kha 4 (66,7%)
2 (33,3%)
0
6 (8,7%)
Kem
0
0
0
0
D i i m Kujaia Tru'O'c mo
46,6
41,2
49,4' 5 2 , 1 ' 44,6
Sau m6
91,2
96,2
87' 96' 93,2
< O001
< 0,001
'Dt6m Kujala trwoc va sau md vai 2 benh nhan tren 14 tudi khong tinh trung binh
TCNCYH 87 (2) - 2014
• TAP CHi NGHIEN CIJU Y HQC Sa khac nhau diem Kujala trad'c va sau mo, trong hai nhdm luoi tren va d u d i 11 tuoi d l u cd y nghla r6 (p = 0,000001; 0,000248). Trong nhdm 9 -11 tudi, tudi trung binh 9 tudi 11 thang (9 tudi 2 thang tdi 10 luoi 9 thang) Diem Kujala 46,5 (36 - 70) trade mo va 91,2 d i l m {76 - 100) tai thdi ijiem ddnh gia sau cting Trong nhdm 11 tdi 14 tudi, tuoi trung binh 13 tuoi 2 thang (11 tuoi 3 thang tdl 13 luoi 10 thang). Diem Kujala 41,2 (32 - 6 1 ) trudc md va 95,2 diem {87 -100) tai thai dilm danh gia sau cung Cd 2 benh nhan tren 14 tuoi, benh nhan thir n h l t 14 tuoi 7 thang, sau m6 7 nam 4 thang Trade mo d b^nh nhan nay cd d i l m Kujala 49,4, sau md cd diem Kujala 87 B6nh nhan thd hai ed tuoi lai thai diem kiem tra sau cimg la 16 tud 4 thang, vd thai gian sau mo la 8 nam 5 thang Diem Kujala trade mo 52,1, sau mo la 96 diem.
Bang 4. K i t qua d i l u trj sai khd-p xu'ang banh che
Dandy va Griffithes 1989 [14]
Madigan 1975 [13]
Chen vS Ramana- than1984[15]
Baksi 1993 [11]
Zeichen 1998 [16]
Hung (trong nghien ci>u nay)
Ky t h u a t
R O I mat ngoai kho'p Chuyen c o rong trong ROI mat ngoai khop Roi mat ngoai kh6p Lam t h i n g p h i n tren co Chuyen phan cheo VIUIO
Benh nhan
41
19
16
36
36
69
Tho'i gian theo roi (thang)
48
29
72
21 - 8 4
75
66
K i t R i t t e t 38
47
38
21
23, 3
68,1 qua p h i l
Tdt 46
11
37
13
3 9 , 9
23, 2
1 thuat (%) Kha Kem
11 5
42
19 6
66
36,8
8,7 0
Su khac nhau d i l m Kujala nhdm < 11 tuoi va > 11 tuoi, ea hai nhdm tudi nay rat khac nhau vdl p < 0,001
Dllm Kujala trung binh trade md 45,3 diem (32 - 70), sau mo 92,4 diem (76 - 100) tai thai dilm danh gia sau eung
Kit qua tai thdi diem danh gia R l t tdt 47 g6i (68.1%), Tdt 16 gdi (23,2%), Kha 6 gdi 18,7%), Khdng ed k i t qua Kem trong nghien ciru nay
Bi^n chii'ng
Mot so bien chdng nha nhiem khuan, hoai
ta da, gay xaang banh che, sai khdp hoac ban sai khdp tai phat deu khdng gap trong nghien ciru nay
Han che van ddng khdp goi 9 gdi
IV. BAN LUAN
Nguyen nhan benh sinh William 1968 thdng bao 26 benh nhan cd cdng khop goi va trong dd 13 benh nhdn cd sai khdp xuong
TCNCYH 87 (2)-2014 125
TAP CHI NGHIEN C U ^ Y HOC • banh ehe, Alvarez 1980 [4], Dennis 1993 (6], Gun 1964 [10], Mukherjee 1980 [5], Sharra- rad 1979 [2], Hung 2008 [7] da thdng bao cdng dudi khdp goi cd sai khdp x a a n g banh che sau tiem khang smh Trong nghien ciru nay, chung tdi nhan t h l y benh nhan d l u ed tiem khang smh va-o ea dui, dui t h u d n g bj teo nhd. Chimg tdi ddng y v d i nhan xet eua William [3] r i n g neu xaang banh ehe daac giu' d v\ tri giai p h l u thi khdp gdi khdng t h l g i p qua 30 dp, goi ed t h l g i p tdl da n l u xaang banh che trat ra ngoai, trong nghien edu nay deu eho t h l y linh trang g i p gdi taang l a Theo Baksi [11] thay ton thaang trong benh ly nay ban d l u la sir co eirng cua ca rdng ngoai, dai chau chay, bao khdp trong;
va ca rdng trong yeu, bao khdp trong Idng la ton thuang thir phat
Ton thu'o'ng giai phau benh ly. ca t d d l u thadng n g l n va xo hda P h l n ldn nhu'ng tradng hap xa hda ca phal trien tdi phan sau eua ca rdng ngoai, ca rdng giira, va tdi ea cang can din tren mat ngoai cua diii va mat tren xuang banh ehe tao nen sa m l t can b l n g v l lue ca trong va ngoai tren xaang banh che tap nen sai khdp x a a n g banh che ra ngoai. Them nira sa xo hda nay lan rdng ldi bao khdp ngoai banh che cho t h l y traat xaang banh ehe < 5 mm khi gdi d l g i p 30°
(bang 1)
Chiing tdl da lam giai p h l u benh ly trong khi mo cho t h l y rd xa hda ca rdng ngoai, ea rdng gida, dai chau c h l y , va bao khdp ngoai, thoai hda ca gap trong ca t h i n g diii, c a rong trong Tinh trang xa hda c a eung gap taang tu trong ea tir d l u , ea tam d l u , ea mdng, ca Delta sau tiem khang smh Sieu am cung cho t h l y tat ca cae trudng hp'p d l u cd xa hda ea rdng ngoai
T i t ea khdp gdi ed bao khdp ngoai d l y va xo hoa, bao khdp trong mdng va rdng, Tuy
nhien p h l u thuat cua chung tdi thyc hien. la phau thuat ngoai khdp, tren to chi>c phan mem, va vdi p h l u thuat tr^n xaang nan tranh a tre em
Baum CH va Bensahel H 1973 [12]; Ben- sahel H, Souchet P, Pennecot GF, va Mazda K [9] da thdng baa b i l n dang trong sai khdp xaang banh che va da n h i n manh khai mem loan san t i l n t r i l n x a a n g banh che (Developmental Dysplasia of the Patella - DDP). Trong nghien cu'u nay, xaang banh ch6 nhd va loan san, t h l y rd nong ranh lien loi c l u , b l n g bet Idi cau ngoai {bang 2).
Ky t h u a t p h l u t h u a t Paletta, nam 1820 Id tac gia d l u lien thdng bao sai khdp xirang banh che bam sinh, tiep sau dd Wuhzer 1835, Lehus 1840, va Miehaelis 1854 Nam' 1959, Cotta [2] da d i l m d a a e 137 phaang phap p h l u thuat eho sai khdp xaang banh ch6
Nhieu phaang phap hdi phue iai cho sal khdp xaang banh ehe da daae gidi thi$u H l u h l l tap trung lam vu'ng mat trong xirong bdnh che hoac gan: thay ddi vi tri ldi ci) tnrdc xaang c h l y theo Rpux 1888, pho biln theo ky thuat nay nha Mauser 1935; Goldthwait 1904 c h u y i n vao trong naa ngoai gan banh ehe, -Galeazzi 1922 c h u y i n gan ca ban gan vd daae phd b i l n bdi Baker 1972, West and Soto-Hall 1958 e l t p h l n xaang banh ch6 vd iam t h i n g lai c o t d d l u , Hughslon 1972 phuc hdi lai ea c h l dudi; Madigan, Wissinger and Donaldson. 1975 chuyen p h l n cheo ca r^ng trong xudng d a d i va ra ngoai tdi mat trirdc xaang banh ehe McGinty and McCarthy 1981, Metcalf 1982 ndi soi lam rdi mSt ngodi cd hoac khdng tao nep mat trong bao khdp.
C a tie d l u d a a c chia lam ba Idp L*P trade cd gan c a t h i n g dui, bam tan tdi c\^
tren xaang banh che. Ldp giu'a gdm ganco rdng ngoai va rdng trong bam tdi m5t ngoSivS trong xaang banh che Lop sau d a a c tgo boi
TCNCYH 87 (2) - 2014
• TAP CHI NGHIEN C l / U Y HOC gan ca rdng giu-a. Tuy nhien, loan b6 lac cho
dudi 10 - 15 do sau cimg de dudi goi la 60%
nhd vao ca rdng trong, Vdi xet neng chp ea rdng trong chp t h l y c a cd hai phan P h l n thing cua ca rdng trong vdi nhdng sai ea hadng theo true x a a n g diii va tac vdi true xuang diii 15 - 18°, VMO tao vdi true eua ' xuang diii 50 - 58°, chdc nang chii y l u VMO la gii> xaang banh ehe vao trong ngan khdng cho xaang banh ehe sai khdp ra ngoai, Fuik- erson 1983 [1] qua nghien ciru giai p h l u va dien ca da k h i n g dmh ehi cd chirc nang eua phln eh6o co rdng trong la duy tri t h i n g hirdng cho xaang banh che
Madigan 1975 [13] va mdl sd tac gia khac chuyen ca rpng trong xudng d a d i va ra ngoai tdi mat trade xaang banh che hoac West 1958 chuyen tdi mat trong gan ca t h i n g diii vdl hy vong lam virng va hadng eho xaang banh chfe vao trong Trong xa hda ca tir dau mdt so ca ciing trong tinh trang co edng (bang 3) VMO thadng giam san va teo nhd hoae thirdng t h i n g han la cheo so vdi giai p h l u binh thudng Chuyen VMO len b d tren xaang banh che nhu chung tdi thac hien da eai thien duac hadng keo cua c a Thac te, do ea teo nhd va cang [2], khdng t h l daa ca nay tdi mat trudc xaang banh eh6 nha ky thuat eCia Madi- gan hoac n l u VMO d a a c khau cd dmh vao mat trudc xaang "banh che, g i p gdi se lam tudt dudng khau hoac han c h l chdc nang g i p gdi sau p h l u thuat Han nira, gde tao nen gi&a VMO va true cCia xaang diii trong p h l u thuat cLJa Madigan, gdc nay se nhd han n l u VMO dapc chuyen l§n b d tren xaang banh cha nha ky thuat p h l u thuat thac hien trong nghi6n cdu nay.
Chimg tdi thong nhat vdi y k i l n cua Stanisavljevics, Zemenich va Miller 1976 phlu thuat iam t h i n g lgi true keo cua ca t d aiu diji se 1^ saa chu'a tdt nhat vdi sai khdp
xaang banh che va ket hap 2 hoac nhilu ky Ihuat ddng thai trong p h l u thuat sai khdp xaang banh che theo nha Volkpv va Dedova 1946 la r l t c l n thilt. Deie 2003 da ket luan p h i u thuat sat khdp xaang banh che khd cd the thu d a a c k i t qua tdt n l u chi t i l n hanh mdt ky thuat Thac t l phaang phap ma chiing tdi thac hien ba ky thuat cho mdl p h l u thuat (1) lao hinh bap khdp, (2) tap hinh eo lir d l u , va (3) chuyin VMO ien bd tren xuang banh che
Chung tdi bao cao k i t qua eua mdt sd tac gia da thac hien p h l u thuat tren p h l n m i m cho sai khdp xaang banh che (d tre em), V. K£T LUAN
Sai khdp xaang bdnh che d tre em cd the xay ra sau tiem khang smh vao ea diii Trieu chirng lam sang ehu y l u vdi diJi teo nhd 100%, xaang banh che n l u gid d vi tri giai p h l u khdng the g i p gdi qua 30°, xuang banh che traat vao trong < 5 mm vdi gdi g i p 30°
gap 100% Gde Q trung binh 14,8° Xuang banh ehe alia gap 20,3%; xuang bdnh ehe nghieng ngoai gap 52.2%; Ranh banh che - dui ndng gap 24,6%, b l n g bet Idi eau ngoai xaang dui gap 14,4% Phuang phdp p h l u thuat "Chuyen p h l n cheo ca rdng trong len b d tren xuang banh che" cho k i t qua r l t tot 47 gdi (68,1%), tdt 16 gdi (23,2%). kha 6 gdi (8,7%), khdng cd k i t qua kem trong nghien ciru nay Ky thuat dan gian, an todn va cd hieu qua vdl xaang chaa tradng thanh d Ire em
Lcy'i cam a n
Tdl xm cam an cae bae sT Khoa Chinh hinh Benh vien Nhi Trung aang da giup tdi trong qua trinh nghien edu
TAI LIEU THAM KHAO 1. Fuikerson JR., Becker GJ., Meaney JA (1990). Anteromedial tibial tuberele trans-
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T^P CHl NGHIEN CIFU Y HOC • fer without bone graft Am J Sports Med. 5, 490 - 497
2. Sharrarad WJW (1979). Developmental contracture of the quadripceps. In Sharrard WJW (ed) Paediatnc Orthopaedics and Fracture Blact^well Scientific Publications, 877 - 880
3. Williams PF (1968). Quadnceps con- tracture J Bone Joint Surg [Br], SOB, 278 - 284, 4. Alvarez EV, Munters M, Lavine LS et al (1980). Quadriceps myofibrosis A compli- cation of intramuscular injections J Bone Joint Surg,4m, 62(1), 5 8 - 6 0 .
5. Mukherjee PK and Das AK (1980).
Injection fibrosis in the quadriceps femoris muscle in children J Bone Joint Surg. 62-A, 453 - 456
6. Dennis RW (1993). Knee pain in chil- dren and adolescents In Dennis RW, Mercer R (eds) ART and Pratice of children's Ortho- paedics Raven Press, New Yorl<, 220 - 255
7. Hung NN (2008), Using an iliotibial tract for patellar dislocation in children Journal of Children's Orthopedic R, 2(6), 342 - 351
o. Cotta H (1959). Zur Therapie der habitullen patellaren Luxation Arch Orttiop Unfallchir, 51, 2 5 6 - 2 7 1
9. Bensahel H, Souchet P, Pennecot GF,
et al (2000). The unstable patella in children, J Pediatr Orttiop, 9(4), 265 - 270
10. Gunn DR (1964). Contracture of ttie Quadriceps Muscle Journal of Bone ami Joint Surgery, 46-B, 492 - 497
11. Baksi (1993). Pes anerinus transposi- tion for Patellar Dislocations Long term Fol- [ovi'-Up results. J Bone Joint Surg [Br]-, 75-B, 3 0 5 - 3 1 0
12. Baum CH, Bensahel H (1973), Luxa- tion recidivante de la rotule chez I'enfant Rev Oiir Orttiop, 59, 583 - 592
13. Madigan R, Wissinger A, Donalson WF (1975). Preliminary Experience with a Method of Quadricepsplasty in Recurrent Sub- luxation of the Patella J Bone Joint Surg, 57A, 6 0 0 - 6 0 7
14. Dandy DJ, Grifiths D (1989). Lateral release for recurrent Dislocation of the pa- tella J Bone Joint Surg [Br]: 71-B, 121-5
15. Chen SC, Ramanathan EBS (1984), The treatment of the patellar instability by lat- eral release Bone Joint Surg [Br]: 66-B (3), 344 - 348
16. Zeichen J , Lobenhoffer P, Bosch U et al (1998). Interim results of surgical therapy of patellar dislocation by Insall proximal recon- struction Unfallchirurg, 101(6), 4 4 6 - 4 5 3
Summary
SURGICAL TRANSFERING VASTUS MEDIALIS OBLIQUE TO PROXIMAL BORDER OF THE PATELLA FOR PATELLAR
DISLOCATION IN CHILDREN
Objective of the study waste evaluate the clinical and functional results of a surgical treatment of patellar dislocation whose etiology was iatrogenic quadnceps fibrosis in children A prospective study was undertal<en from February 2004 to December 2010 The study included 65 pediatric patients (69 knees) who have developed dislocation of the patella after repeated intramuscular injections of antlbiotic(s) into the quadnceps muscle There were 14 males (21 5%) and 51 fe- males (78 5%) The patients' mean age at surgery was 7 years, 2 months Patellar dislocation was classified according Bensahel's criteria In alll patients, the vastus medialis oblique was trans-
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•^^j#lWiiiffiltl^*ip^
ferred to the supenor border of the patella There has been no poor posl-surgical result or recur- rence so far; limitation of the knee flexion occurred in 6 knees {8.7%), and loss of extension of 5 - 20" in 6 knees (8.7%). Overall, we attained excellenl results in 47 knees (68.1%), good results in 16 knees (23.2%), and fair results in 6 knees (8,7%). In conclusion, the transfenng of the vastus medialis oblique to Ihe superior border of the patella vi/as highly successful in restohng the realignment mechanism of the knee. The technique is simple, safe and effective in skeletaliy immature children.
Keywords: patellar instability; patellar dislocation, quadricepsplasty, subluxation of the patella, developmental dysplasia of the patella (DDP)
TCNCYH 87 (2)-2014