NOI KHOA - SO 4/2009
NGHIEN Ctru LAM SANG, MAT DO XlTONG VA BIEN CHlTNG (3 BENH NHAN GAY CO XlTONG DUI
Le Thu Ha, Luu Hong Hai*, Vii Thi Thanh Hoa*, Nguyen Vift Khoa*, Nguyin Nang Gidi*
TOM TAT
Muc tieu: nghien cu\i dac diem lam sang, mat dp xu'dng va bien chiTng d benh nhan gay cd xu'dng diii (GCXD). Doi tUOng nghien ciJ'u:
62BN GCXD dieu trj tai khoa Chan thu'dng chinh hinh - Benh vien 108. Phu'dng phap nghien cihi: tien diu, md ta cat ngang. Ket qua: Tudi trung binh nhdm nghien cuU 74,7 ± 9,77 tudi, ti le nii': nam 1,8:1. Gay cd chinh danh xu'dng diii chiem 64,5%, 7 1 % BN du'dc dieu trj bang thay khdp hang ban phan bipolar. Ti le loang xu'dng la 52% vd thu'a xu'dng 44%, chi cd 7/62BN (11,3%) du'dc dieu trj loang xu'dng sau gay xu'dng. Bien dhuhg nhiem khuan la thu'dng gap sau GCXD: 14,5%, loet diem ty va suy mdn (4,8%). 41,2%BN chuci phue ho! van ddng sau 3 thang gay xu'dng, sau 1 nam gay xu'dng cdn 2,5%BN phai nam tai giu'dng. Tir vong trong nSm dau 5,4%.
*Tit' khoa. mat dp xu'dng, gay cd xu'dng dill
ABSTRACT
CLINICAL SIGNS AND SYMTOMPS, BONE MINERAL DENSITY AND COMPLICATIONS
IN HIP FRACTURE PATIENTS
Objectives: To describe clinical signs,BMD,compllcations in hip fracture patients.
Subjects: 62patients with hip fracture who were treated at Department of Trauma and Orthopedics in Central Military hospital 108.
Methods: Descriptive and prospective study.
Results: Mean age is 74,7 ± 9,77 years, female
*B4nh vl^n Trung uang qudn d^i 108.
and male ratio is 1,8:1. Femoral neck patients accounted for 64,5%. 7 1 % patients were treated with bipolar hemiarthroplasty. Osteoporosis rate is 52% and 44% patients with osteopenia;
however only 7/62 cases (11,3%) were treated with anti-osteoporotic drugs after hip fracture.
Infection is a more common complication (14,5%); 4,8% patients had pressure ulcers and cachexy. 41,2% patients hadn't recovered their mobilities after 3month-hip fracture. In the first year-hip fracture, bed-ridden rate was 2,5% and the mortality was 5,4%.
Keyword. BMD-bone mineral density; Hip fracture
I. DAT VAN DE
Gdy cd xuomg dui (GCXD) la mpt teong nhflmg vdn dl siic khde cpng ddng do ti If hi vong vd tdn phi cao, chdt lupmg sing ciia ngudi bfnh gidm dang kl ngay cd khi bfnh nhan (BN) da dugc xir Ui tich cvrc. TCYTTG udc tinh ndm 2025, thi gidi cd 2,6 trifu ca GCXD. 6 My, GCXD mdi d ngudi > 65 tudi: 350ca/l00.000 dan. T?d Chdu A, ti If GCXD cao nhdt d Hdng Kdng vd Singapore tuong ling 459ca/l 00.000 dan vd 442ca/l 00.000 dan ddi vdi nii. Biln chiing sau GCXD rdt nang nl: tan phi, nhiem khudn, loet diim ty... 12%-20%BN se hi vong trong ndm kl tilp, 40%BN khdng hdi phvic churc ndng khdp, cdn trpr giiip trong ndm ddu GCXD [2]. Chi phi chdm sdc y tl cho GCXD khd ldn. T?u My, chi phi Uung binh
CHUYEN OE: CO XUONG KHOP - NHtJTNG Ti^N BO TRONG CHAN POAN VA PliU TRj
lea GCXD la 29.800 do la; udc tinh nam 2020, tdng chi phi hang ndm cho dieu tri GCXD se khoang 31ti do la. Nguy ca hdng ddu cho GCXD Id giam mat dd xuomg d co xuomg dui, ngudi cao tudi, te ngd....
Tai Vift Nam ddi sdng xd hpi dugc cdi thifn nen tuoi thp trung binh ngudi dan ciing tdng len, hifn nudc ta cd khoang 7,3 trifu ngudi cao tudi nen GCXD la nguy ca ldm vdi cpng ddng vd la vdn de cdn quan tam cua nganh y tl. Tuy da cd nhilu nghien curu ve loang xuomg nhung chiing ta cdn it cac nghien cuu v l biln chiing sau gay cd xuomg dui. Chiing tdi tien hanh "Nghiin cuu ldm sdng, mgt dp xuang vd biin chiing d binh nhdn gdy co xuang duf nhdm cdc miic tieu sau:
1. Nhdn xet ddc diim ldm sdng, mat dp xuang d bfnh nhdn gay co xuang diii.
2. Theo doi biin chiimg sau gay cS xuang diii trong thdi gian 1 ndm.
I I . DOI TUONG VA PHU'ONG PHAP NGHIEN CUtJ
1. Dli tugrng nghien cihi
-62 bfnh nhan GCXD dugc diiu tri X^\
khoa Chdn thuomg chinh hinh - bfnh vifn TLTQD 108 tir thdng 11/ 2006 din 4/ 2008.
Tieu ehudn loai trir: GCXD do mdt bfnh ly todn than hodc do tai nan giao thdng;
Bfnh nhdn khdng hgp tdc nghien curu.
2. Phuong phap nghien cuu: tien curu, md td cdt ngang.
Ndi dung nghien cim: BN dugc kham lam sang, can lam sang theo mau bfnh an thdng nhdt. Theo ddi khi BN tdi kham sau 3 thang, 6 thdng, Indm hodc hdi qua difn thoai.
o Lam sdng: tham Idiam toan difn xdc dinh tudi, chilu cao, can ndng, BMI, bfnh kit hpp, phuang thuc diiu tri, phue hdi van ddng sau dieu tri.
o Can lam sang: (1) Cdng thiic mdu va sinh hda mdu thudng qui; (2) XQ tim phli;
(3). Do mat dp xuomg (MDX) theo phuong phdp DEXA (Dual Energy X-ray Absorptionmetry) bdng ""mdy Hologic cua My. Vi tri: cd xuomg dui khdng bi gay, cpt song thdt lung Ll -•L4.Dan vi MDX: g/cm^
chi so T-score. Chdn dodn lodng xuomg theo WHO 1994 (T-score).
o Theo ddi biln chiing khi ndm vien, 3thang, dthang, Indm sau GCXD.
3. Xu ly so lieu: phuomg phap thing ke y hpe dvra tren phdn mIm SPSS.
I I I . KET QUA NGHIEN CUtJ
1. D^c diem chung cua nhdm nghien cihi.
2 1 2 ' X X 2 X
Bang 1. D^c diem ve tuoi, gidi, chi so khoi ca the, bfnh ket hop Thong so
Tuoi (n=62) Gidi (n=62) BMI (n=62)
> 60 tuoi
< 60 tudi Nam
NO'
< 18,5 18,5 - 23
> 2 3 -
So luTtfng b§nh nhan 57
5 22 40 12 45 5
Ti le (%) 91,9
8.1 35,5 64,5 19,3 72,6 8.1
D
< 0,001 0,02 0,002
NOI KHOA - SO 4/2009 B|nh ket htfp Tang huyet ap
Dai thao du'dng Tai bien mach nao cu
Benh phoi man tinh Suy tim Thieu mau Protid mau thap
Khac
21
16 22
33,9
14,5 9,7 AA.
AA.
25,8 35,5
A2A.
Nhan xet: Cdc BN chu yiu cd dp tudi > 60 chilm 91,9%. Tudi trung binh: 74,7±9,77Uidi (47-89hidi). Thdi gian tir khi GCXD din khi nhdp vifn:7,52±22,43 ngdy (l-50ngay). Ngdy ndm diiu tri tnmg binh: 15,4 ± 6,21 ngdy (5 - 30ngdy).
Nhumg bfnh ndi khoa thudng gap d BN GCXD Id: tdng huyit dp: 33,9%, ddi thao dudng:
14,5%, tai biln mach nao cii 9,7%. 25,8%BN cd thilu mau vd 35,5% bfnh nhan cd protid mdu thdp.
Bang 2. Hinh thai gay co xuong diii
V[ tri gay Gay lien mau chuyen Gay CO chinh danh Gay nen cd
Tong
So lu'dng benh nhan 20
40 2 62
Ti I I (»/o) 32,3 64,5 3,2 100
Nh$n xet: Gdy co chinh danh xuomg dui Id chu yiu; 64,5%. Trong dd, 71% BN dugc thay khdp ban phdn Bipolar, 22,6% BN kit xuomg bdng ddng dinh Ender hodc vit xdp; Chi cd 6,4% bfnh nhan diiu tri bdo tdn.
2. Tinh tr^ng lodng xuotig d bfnh nhdn gay cl xuorng diii Bdng 3. Ti If loang xuong & bfnh nhan gay cl xuomg diii
MDXdc5 xu'dng diil So lu'dng BN
Ti le (%)
Binh thu'dng (T-score > - l )
1 AL
ThUa xu'dng (-1 > T-score > -2,5)
11
44>0
Loang xu'dng (T-score$-2,5)
13
52,0
Tong
25 100 Nhfn xdt: 52,0% bfnh nhdn cd lodng xuomg vd 44% cd thua xuomg. T-core tnmg binh:- 2,35±0,95 (-4,2-»-0,3). MDX trung binh d cd xuong diii:0,61±0,14 g/cml Ti If cdc bfnh nhdn dugc diiu trj loang xuang sau GCXD Id thdp: sau thdng thur nhdt vd thdng thii 3 cd 7/62 bfnh nhdn (11,3%), sau thdng thir sdu cd 5/49 bfnh nhdn (10,2%), d thdng thii 12 cd 5/39 bfnh nhdn (12,8%).
C H U Y E N pi: CO XJONG K H O P - N H O N G TIEN BO TRONG CHAN POAN VA PIEU TRj
3. Bien chung ciia gay co xuong diii.
Bang 4. Bien chung ciia gay cd xuomg Bien chufng
Viem phdi
Nhiem khuan huyet Nhiem khuan tiet nieu Loet diem ty
Suy mdn Dau tai cho
Van dpng Ngd! xe day Nam tai cho Tir vong
Khi nam vien (n=62)
n 3 .2 4 2 1 62
o/o 4,8 3,2 6,5 3,2 1,6 100
diii
Sau 3 thang ( n = 5 9 ) n 1
2 3 49
19 5 1
•>/o
1,7
3,4 5,1 89,1 32,7 8,5 1,7
Sau 6thang ( n = 4 9 ) n 2
1 3 16
5 1 1
o/o 4,3
2,2 6,5 38,1 10,6 2,1 ^ 2,2
Sau 12thang (n=39) n 1
1 2 7 . 1
1 2
o/o 2,6
2,6 5,1 22,6
2,5 2,5 5,4
Nhan xet: Biln chiing sau GCXD thudng gap la nhiem khudn 14,5%. Sau 3. thang diiu tri vdn cdn tdi 1/3 BN phai ngdi xe ddy (32,7%), 2,5% BN ndm tai chd sau Indm. Ti If tu vong trong nam dau la 5,4%.
IV. BAN LUAN
1. Ddc diem chung ciia nhdm nghien cuu.
Nghien cuu cua chiing tdi gdm 62BN GCXD, ti If nii- la 64,5%. Tudi BN nghien ciiru dao ddng tir 47-89, chu yiu >60tudi:
91,9^. Sd lieu ciia chiing tdi ciing tuomg tvr vdi Steven Boonen, Remy M.Tjeenk, Sandy B.Ganz [8,9,10].
Nhdm BN cd BMI thdp < 18,5 la 19,3%.
Ngay ndm dieu tri trung binh cua BN chiing tdi la 15,4±6,21. Leonard M.F. Rademakers thdy BN GCXD cd loet diem ti cd ngdy ndm vifn 19,5ngdy ddi.hom BN khdng bi loet 8,4 ,.
ngdy, p=0,001[5]. Remy M.Tjeenk lai thdy ngdy ndm diiu tri trung binh cua BN GCXD tdi 38 ngdy (1-181 ngdy) [5]. Cd thi do doi tugng nghien curu ciia hp cd nhilu biln chiing ndng sau md, cd benh ndi khoa nang ket hgp nhu suy tim, tai biln mach ndo cii, viem phdi...
Bfnh npi khoa sdn cd d BN chiing tdi chii yiu la tdng huyit dp (33,9%), ddi thao
dudng (14,5%), tai biln mach nao cu (9,7%), ngodi ra cdn gap suy than, suy tim... nhung gap vdi ti If thdp (< 5%). 25,8% BN nghien curu cd thilu mdu vd 35,5% cd protid mau thap. Sd fifu cua chiing tdi ciing phu hgp vdi tac gid Steven Boonen [10]. Theo Sandy B.
Ganz, cdc benh kit hgp cd thi gap d BN GCXD la benh tim mach: 78%, tai biln mach nao cu: 24%, trdm cam: 26%, benh phdi man tinh: 15%, loang xuomg: 13%^ tiln sut gay xuomg: 19%[9]. Gay co chinh danh xuong diii la lo£ii gay chii yiu cua BN chiing tdi (64,5%). Kit qua nay phii hgp vdi ddc thu bfnh nhan nghien cuu cd tudi cao kit hgp vdi tinh trang thua xuomg, loang xuomg ndng (96%). 71% BN nghien cim dugc thay khdp hang ban phdn bipolar. Ddy cung Id nhiing tilribd dang khieh If trong diiu trj GCXD d nudc ta. Chinh do v§ly nen kit qud chung sau phau thuat Id khd quan. 6,4% BN diiu tri bao ton do tinh trang todn thdn ndng ne khdng the chi dinh phdu thudt dugc.
NQI KHOA - SO 4/2009
2. Tinh tr^ng loang xuomg d bfnh nhan gdy c l xiromg diiL
Theo Lois E. Wehren, ti If lodng xuomg d bfnh nhdn GCXD (T-score<-2,5) Id 79,3%[6]. Theo cdc nghien ciiu d Vift Nam, Nguyen Thdi Thdnh thdy lodng xuomg d bfnh nhan GCXD Id 77,5% [3], trong nghien cim cua chiing tdi, ti If nay Id 52%. Ti If loang xuomg cao d bfnh nhdn GCXD do cd nhumg ylu td thuan Igi nhu tudi cao, BMI thdp, vdn dl bd xung canxi, vitamin D... trong chi dp dn cda BN, nhdn thiic cua ngudi dan vf van dl siic khde ndy. Nhieu nghien curu da chi ra Cli giam 1 dp Ifeh ehudn ciia mdt dp xuomg (0,12g/cm^) nguy ca GCXD tdng 2,6-4ldn (nghifn cim SOF, DOES, EPIDOS). Tuy nhien du ti If lodng xuomg d bfnh nhdn GCXD cao nhung cdn it BN dugc cdc thdy thudc chi dinh diiu tri loang xuomg sau gay xuomg. Theo Martien J.M.Pannemnan (Ha Lan) ciing chi cd I5%BN sau gay xuomg cd dieu trj loang xuomg chu ylu bdng thudc nhdm biphosphonates[7]. Trong nghien cihi cua chiing tdi ti If nay cdn thdp hom 7/62BN (11,3%). Sd BN ndy tilp tyc gidm trong 6-
12thdng sau (5BN). Dang luu y la nhumg BN dd GCXD van se cd nguy ca mdt xuomg tilp tvic do bdt dgng Idu, thilu duomg, gidm siic CO... Ddy ciing la vdn de cdn dugc quan tam hom trong ngdnh y t l chiing ta.
3. Biln chung cua gay co xuomg diii.
Ti If biln chiing sau GCXD d BN nghien ciiu tuy khdng cao nhung cd nhiing biln chiing ndng. Trong thdi gian ndm vifn biln chiing nhiem khudn ndng gdp 8,0%
(4,8%viem phdi, 3,2%nhiem khudn huyit);
nhiem khudn tilt nifu 6,5%; 4,8%BN loet diim t^ vd suy mdn. Cdc biln chung tilp tue cd d nhflmg thdng tilp theo. 1 nam ddu sau gdy xuomg chiing tdi cd 4 ca viem phdi, 3 ca loet diim ty vd suy mdn. Ngodi ra cdc BN
cdn dau tai cd xuomg did gay du ti If dugc kit xuomg tuomg ddi cao: khi ndm vifn, ti If ndy Id 100% vd sau 1 ndm van cdn tdi 22,6%
BN van dau t^ cho. Tir vong Id Win chiing ndng nhdt gap d 4BN (Inur, 3nam), nguyfn nhdn la do viem phdi (2ca) vd xudt huyit ndo (2ca). Ket qud nghien ciiu ciia chiing tdi ciing phu hgp vdi Sandy B.Ganz. Steven Boonen thdy tdi 13% BN tit vong sau 1 ndm (nhdm chiing 3%, p< 0,001). Theo Leonard M.F.
Rademakers cd 29%BN GCXD bi nhifm khudn khi ndm vifn (19,5%nhiem triing tilt nifu, 6,l%viem phdi, 3,3%nhiem trimg vlt md, nhiem khudn huyit 1,4%), 30% loet diim ty ngay cd khi BN dugc xii tri sdm[5].
71%BN chiing tdi dugc thay khdp hang bdn phdn bipolar, nhung tdi 32,7%BN vin ngdi xe ddy vd 8,5%BN ndm t?ii cho sau 3 thdng;
sau 1 ndm cdn 2,5% BN ndm t^ cho. Theo cdc tac gid khde, ti If bfnh nhan cdn trg giup trong sinh ho^t cdn cao hom nghifn ciiu ciia chiing tdi rdt nhilu. Steven Boonen thdy 30%BN < 80tudi cd GCXD cdn svr ho trg trong sinh ho?it (nhdm chiing 7%, p<0,001);
ti If nay len tdi 56% nhflmg BN > 80 tuli;
24% mdt churc ndng khdp sau Indm GCXD.
Hannan EL thdy 12,8% BN tdn phf sau 6 thdng GCXD[4]. Nhu vdy vdi BN GCXD cao tudi, tinh trang todn than anh hudng Idn din hoi phvic siic khde cua hp du dd dugc kft xuong sdm. Sd lifu nghifn cuu ciia chiing tdi chua nhilu vd vifc qudn li bfnh nhdn ngo^i tni cdn nhilu bdt cap nen cdc nhdn xet ciia chiing tdi mdi chi Id bude ddu, cdn cd sd lifu nghien ciiu Idn hom nura.
V. KET LUAN
Qua khao sdt lam sdng, mat dp xuomg vd mpt sd biln chiing d 62 bfnh nhan GCXD chiing tdi nhdn thay:
CHUYEN p i : CO Xl/ONG KHOP - NHQTNG TIS'N B 6 TRONG C H X N POAN VA PliU TRj 1. Dp tudi trung binh bfnh nhdn GCXD
la 74,7 ± 9,77 tudi vd chu yeu la nii gidi, 64,5% la gay cd chinh danh xuomg diii, 71%BN dugc thay khdp hang ban phdn Bipolar. Cac benh ndi khoa ket hgp gap Id tdng huyit dp (33,9%), dai thao dudng (14,5%), di chiing tai biln mach nao (9,7%), thieu mau (25,8%), protid mau thap (35,5%).
52% benh nhan cd loang xuomg va 44% cd thua xuomg. Chi khoang 10% benh nhdn dugc phdi hgp dieu tri loang xuomg
2. Bien chiing cua bfnh nhan GCXD trong giai doan nam vien la nhilm khuan ehiem 14,5% gdm viem phdi, nhiem khudn hiiyet, nhilm khuan tiet nieu; 4,8%BN cd loet diem ti vd suy mdn. Trong 1 nam dau sau GCXD cd 6,4% benh nhan bi viem phdi, 4,8% ca cd loet diem ty va suy mdn, 5,4%
BN tir vong. Mdt trudng hgp phdi nam tai giudng.
*Kien nghi: Ben canh ket xuomg khdi phvic van ddng, cac benh nhan GCXD cao tudi cdn dugc quan tdm tdi chan doan vd diiu tri lodng xuomg.
TAI LIEU THAM KHAO
1. Tran Ngoc An (1999), "Binh loang xuang", Bfnh thap khdp, tai ban ldn thur 6, Nha xudt ban Y hoc, tr 22-32.
2. Tran Dinh Chien, Nguyen Ngoc Thao.
"Gay xuang diii" Benh hoc Chan thuang chinh hinh. Nha xuat ban Quan doi nhan dan.
2006, tr. 94-117
3. Nguyin Thai Thanh."Z,Mpwg gid nigt dp xuang do bdng plwang phdp DEXA vd khdo sdt cdc yeu to ngt^ ca a benh nhdn nir gdy co xuang diii tgi B^nh viin Chdn thuang. chinh hinh TP. HS Chi Minh" Tap chi YHLS so 9/
2007, tr. 42-47.
4. Hannan EL et al. "Mortality and locomotion 6months after hospitalization' for^ hip fracture: risk factors and risk-adjusted hospital outcomes" JA1VIA2001; 285(21):
2736-42
5. Leonard M.F.Rademakers et al. "Pressure Ulcers and prolonged hospital stay in hip fracture patients affected by time-to-
surgery" Eur Jour Trau and Emer Surg 2007; 33: 238-44
6. Lois E.Wehren et al "Predictor of bone loss after hip fracture" Osteoporos Int (2004) 15:
125-131.
7. Martien J.M.Pannenman et al
"Undertreatment with anti-osteoporosis drugs after hospitalization for fracture"
Osteoporos Int (2004) 15: 120-124.
8. Remy M.Tjeenk et a\."Mortalify Registration in patients with a proximal femoral fracture admitted to a surreal
ward' Eur Joumal of Trauma 2002;28:95-9 9. Sandy B. Ganz et al. '^Functional recovery
after hip fracture in the Subate Setting.
HSSJ (2007) 3: 50-57
10. Steven Boonen et al."Functinal outcome and QOL following hip fiacture in elderly women: a prospective controlled study"
Osteoporos Int (2004) 15-87-94.
