! !'.jr l i e * ! - % A i 1 Y HOC VIET NAM THANG 10 - SO 2/2010
DANH GIA KET QUA DIEU TRj KHUYET HONG PHAN MEM
c a QUAN VAN DONG B A N G CAC VAT DA CAN CO CUONG MACH LIEN TAI BENH VIEN DA KHOA TRUNG iTONG THAI NGUYEN
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T O M T A T .';i^!t'ai^^7fJ».!.^i,W7 ,.•:;'•
Muc tieu: Oanh gia ket qua dieu tri khuyet hong phan mem cd quan van dgng bang cac vat da can cd cudng mach lien. Ddi tUdng: gom 32 benh nhan cd khuyet hdng phan mem cd quan van dgng dUdc dieu trj ngi tru tai khoa Chan thUdng chinh hinh, Benh vien da khoa Trung Udng Thai Nguyen. Thdi gian nghien ciru: tii 2/2008 den 9/2009. PhUdng phap nghien citu:
mo ta. Ket qua va ket luan: sd benh nhan bj tai nan giao thdng chiem ty le 46,9%, nam/nii' la 4/1. Tai nan lao dgng la 28,1% va toan bg la nam. Tai nan sinh hoat chiem 18,8%, nam/nu' la 3/1. KHPI^ do vet thUdng loc, mat da la 53,1%, bong sau 15,6%. loet diem ty 18,8%, loet lau lien 12,5%. KHPM d chi tren chiem 46,9%, chi dudi la 53,1%. Sd benh nhan bj KHPM cd kich thudc >6-15cm chiem ty le 62,6%, <5cm la 37,4%. Ton thUdng phdi hgp gay xUdng la 52,4%, tdn thUdng gan, Id gan la 47,6%. PhUdng phap trir dau bang gay te viing chiem ty le 87,5%, gay me 12,5%. Che phii KHPM bang vat hien cuong ngoai vi la 40,6%, vat dieu bay 15,6%, vat luiig ke ngon 15,6%. vat bap chan trong 12,6%, vat lien cdt sau 9,3%, vat gan tay 6,3%. Sd benh nhan dUdc ghep da tU than tai vj tri boc vat chiem ty le 71,9%, khau kin vet mo la 28,1%. Cd 24/32 (75%) sd benh nhan phau thuat 1 lan, sd benh nhan phai phau thuat 2 lan la 25%. Mirc dp sdng ciia vat tdt chiem ty le 84,4%, vira 6,3%, xau 9,3%. Danh gia seo sau khi ra vien cd seo mem mai chiem ty le 85%, seo Idi la 15%,
Le Phi Long*, Hoang Van Dung*
Nguyen Cong Bang,* va cong su
chirc nang va tham my chap nhan dugc. i .i SUMMARY
Background: evaluate the outcome of the treatment of soft tissue defects with pedict flaps.
Objective: 32 patients with soft tissue defects, who are inpatients treatment in traumatology and orthopedic department. Time from 2/2008- 9/2009. Subjects and methods: description.
Results and conclusion: patients with traffic accidents: 46,9% in which male/female: 4/1;
occupatienal accidents: 28,1% all them are male;
accident activities: 18,8% in which male/female:
3/1. Soft tissue defects by the loss of skin and skin avulsion: 53,1%, deep burns 15,6%, ulcer points: 18,8%, ulcers often associated: 12,5%.
Soft tissue defects on arm: 46,9%, on leg:
53,1%. Patients with soft tissue defects >6- 15cm: 62,6%; <5cm: 37,4%. Combination fracture injuries: 52,4%; tendon injuries and tendon expose: 47,6%. Methods except the pain with anesthesia: 87,5%; anesthesia: 12,5%.
Cover the soft tissue defects by Sural island flaps: 40,6%; Pedicled Dorsal Digital flaps:
15,6%; back alternative finger flaps: 15,6%;
Medial Sural perforator flaps: 12,6%; Posreior interosseous flaps: 9,3%, thenar perforator flaps:
6,3%. The patients who were split skin grafted on peeled flap: 71,9%; Close wound surgery:
28,1%. The patients who were surgeried 1 time:
75%, 2 times: 25%. The level of living of the good flaps: 84,4%; median: 6,3%; bad: 9,3%.
Klioa Chdn tliuang Mnh liinit - B?nii vi?n da litioa TW Tlidi Nguyen
HOI CHAN THUONG CHJNH H I N H VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN T H U I X 20 patients were examined after 3 months: scar
soft: 85%; convex scar: 15% function and aesthetics may be more acceptable
I. OAT V A N o f
Trong nhieu nam trudc day de dieu tri cac khuyit hong phan mem ngudi ta thudng dung cac each nhu ghep da vdi do day mdng khac nhau, vat bit cheo chi hay vat hinh tru Filatov- Gillis, thi nhung cac phuong phap nay cdn bdc Id mdt sd nhihig nhugc diem nhu la phai phau thuat nhieu thi, cham sdc khd khan. Trong vai thap ky trd lai day nhieu tac gia tren the gidi ciing nhu d Viet Nam da nghien ciiu va iing dung dieu tri khuyet hdng phan mem bang cac vat cd cudng mach lien da dem lai hieu qua rat dang khich le. Tai khoa Chan thuang chinh hinh Benh vien da khoa Trung uong Thai Nguyen ciing mdi bat dau img dung dieu tri cac khuyet hdng phan mem bang cac vat cd cudng mach lien va da dem lai mdt ket qua budc dau kha quan. Cac khuyet hdng phan mem la tdn thuong thudng gap do nhieu nguyen nhan khac nhau nhu: tai nan lao ddng, tai nan giao thdng, tai nan sinh boat gay nen cac tdn thuong sau, rdng nhu Id gan, CO, xuong, khdp. De dieu tri cac tdn thuong nay nhat la d nhiing vimg khdp, viing ty de ddi hdi phai su dung phuang phap tao hinh che phii bang cac vat nhu: vat co, vat da can, vat da co...de dam bao chiic nang sinh ly tai chd ciing nhu finh tham my cho ngudi benh. Tir thuc te tren chiing tdi tien hanh nghien ciiu de tai nay nham hai muc tieu sau:
1. Mo td cdc hinh thdi ton thuang trin lam sdng
2. Ddnh gid kit qud diiu tri khuyit hong phdn mim bdng cdc vgt da cdn co cudng mgch liin
II. o 6 l TUONG VA PHUONG PHAP NGHIEN COU
2.1. Doi tu-gng nghien cihi
- Gom 32 benh nhan cd khuyet hdng phan mlm co quan van ddng dugc dieu tri ndi tni tai khoa Chin thuong chinh hinh, Benh vien da khoa Trung uong Thai Nguyen.
- Tieu chuan chgn benh nhan: nhiing benh nhan cd khuyet hdng phan mem sau viing CO quan van ddng do mgi nguyen nhan.
- Tieu chuan loai trir: nhiing benh nhan cd khuyet hdng phan mem ndng, hep khong cd chi dinh sir dung vat cudng lien, benh nhan cd di tat bam sinh
2.2. Thoi gian va dia diem nghien cmi:
- Thdi gian nghien ciiu: tir 2/2008 din 9/2009
- Dia diem nghien ciiu: Khoa Chin thuong chinh hinh Benh vien da khoa Trung uong Thai Nguyen
2. 3. Phuong phap nghien cihi
2.3.1. Thiet ke nghien cieu: Nghien ciiu mdta ' ' ..
2.3.2. Cdch chgn mdu: Chgn mau cd chu dich 2.4. Chi tieu nghien cmi
- Phan loai nguyen nhan theo tudi, gidi - Hinh thai tdn thuong,vi tri, kich thudc tdn thuong, tdn thuong phdi hgp
- Danh gia ket qua dieu tri, cac loai vat che phii khuyet hdng, muc do sdng cua vat, bien chiing sau phau thuat
2.5. Ky thuat thu thap so lieu
- Phdng van true tiep de khai thac tuoi, gidi, nguyen nhan tdn thuong
- Kham lam sang trudc va sau md Cac budc tien hanh:
+ Kham lam sang, xet nghiem (cac xet nghiem trong gidi ban cho phep phlu thuat) dugc sir dung trong chan doan.
-I- Danh gia tdn thuong: vi tri ton thuang, kich thudc tdn thuong chilu dai, chilu rgng (cm): Id gan, hoai tir gan. Id xuong, khdp.
Y HOC VIET NAM THANG 10 - 3 0 2/2010
+ Ve thilt kl vat dua theo tdn khuyit cua timg benh nhan. Chup anh tdn thuong va vat dugc thiet kl.
+ Tiln hanh phau thuat: tuy tinh trang tin khuyit ma quylt dinh sii dung cac vat khac nhau de che phu.
+ Theo ddi sat su sdng cua vat va tai vi tri liy vat trong thdi gian dilu tri
+ Danh gia ket qua gan dugc thuc hien trong 3 thang dau sau md
+ Danh gia chirc nang va tham my ciia vat khi benh nhan tai kham: sau thdi gian ngoai 3 thang.
- Tieu chuan danh gia
Can cii vao tieu chuan danh gia ciia OberlinC. VaDuparcJ[l]
* Ket qua gan: (trong 3 thang diu sau mo) + Tdt: Vat sdng hoan toan, tdn thuong lien seo khdng viem rd.
+ Vim: Vat thieu dudng, xuat hien phdng nudc tren be mat hoac hoai tii mep vat, cd hoac khong phai ghep da bd sung. Hoac vat bi hoai tu ldp da nhung cdn ldp can mo.
+ Xau: Vat bi hoai tir tren 1/3 dien tich den hoai tir toan bd, phai cat bd va thay the bang phuong phap dieu tri khac
* Ket qua xa. (tren 3 thang)
+ Tdt: Vat mem mai, di dgng tdt, khdng bi trgt loet, khdng tham den, tdn thuong khdng bi viem rd.
+ Vira: Tdn thuang bi viem rd keo dai, nhung chi can nao rd thay bang, khdng phai tao hinh phii bd sung.
+ Xau: Vat bi xo cimg, tham den, chgt loet hoai tir din, tdn thuong bi viem rd keo dai, phai tilp tuc tao hinh phu hoac tao hinh ddn d khuyet hdng
2.6. Xir ly so lieu
Phuang phap thdng ke y hgc, sir dung tren phan mem Epiinfo version 6.04. tren may vi tinh
2.7. Dao due trong nghien cmi
Trong nghien ciiu nay tit ca nhiing benh nhan deu hai ldng va cd thai do hgp tac tdt trong cdng tac kham, dieu tri va cham sdc
Ket qua dieu tri.
III. KET QUA NGHIEN CCfU VA BAN LUAN Bang 1: Phan loai tdn thuong theo gidi
~~— - _ _ _ _ ^ Gidi Nguyen nhan ton thUdiig~ — • — Tai nan giao thdng
Tai nan lao dgng Tai nan sinh hoat Tong
Nam 12
8 6 26
Nu' 3 1 2 6
n 15
9 8 32
o/o 46,9 28,1 25 100
Ket qua nghien ciiu cua chiing tdi cho thay sd benh nhan bi khuyet hdng phan mem nguyen nhan do tai nan giao thdng chiem ty le cao nhat 46,9% trong dd ty le nam la 81,25%.
Cdn cac nguyen nhan khac chiem ty le thap.
Bang 2: Phan loai tdn thuong theo tudi Tuoi Nguyen nhan ton thu'dng Tai nan giao thdng
< 1 8 19-39 >40
15
HOI CHAN THUONG CHINH H I N H VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN T H U IX Tai nan lao ddng
Tai nan sinh hoat Tdng
%
2 2 8 25
6 5 20 62,5
1 1 4 12,5
9 8 32 100
Liia tudi thudng gap nhat la do tudi tir 19- 39 chilm 62,5%, day la do tudi lao ddng ciing nhu tham gia giao thdng chu ylu. chinh vi vay tdn thuong hay gap d liia tudi nay
Bang 3; Hinh thai tdn thuong
Hinh thai ton thu'dng Bdng sau
Vet thUdng Idc, mat da Loet diem ty
Loet lau lien Tdng
So trUdng hdp 5
17 6 4 32
»/o 15,6
53,1 18,8 12,5 100
Cd nhieu hinh thai tdn thuong tren lam sang nhung ddi vdi nhiing tdn thuong ldc da ve sau da ldc bi hoai tir,hay nhiing vet thuong mat da thudng phai phau thuat tao hinh phii bing cac vat da, loai nay chiem 53,1%) trong cac loai tdn thuang ma phai dimg vat da dl che phu.
Cdn nhiing hinh thai tdn thuong khac nhu bdng sau, loet lau lien hay do ty de gap it hon Bang 4: Vi tri tdn thuong . ,,, , ,, ...
Vitri Chi tren Chi dudi
Phai Trai
Phai Trai Tong
So benh nhan 9 6 8 9 32
o/o 28,1 18,8 25 28,1
100
Vi tH tdn thuong tren lam sang chiing tdi thay rang ti le tdn thuong can tao hinh phu d chi dudi chiem 53,1%) nhieu hon chi tren khdng dang ke
« ! • '
Bang 5: Kich thudc tdn thuong Du'dng kinh ton thUdng
< 5cm 6-9cm 10-15cm
Tdng
So tru'dng hdp 12 10 10 32
o/o 37,4 31,3 31,3 100 Nhan xet: sd benh nhan cd kich thudc tdn thuong > 6 cm chiem ty le cao 62,6 %
Ti le nay cao nguyen nhan la trong 32 trudng hgp thi cd 15 trudng hgp chiing tdi sir dung vat hien dl che phu vimg 1/3D cing chan, mit ca chan va cii gdt va nhirng tdn thuong nay thi kich thudc tir 6-10 cm chiem chu yeu.
Y HOC VIET NAM THANG 10 - SO 2/2010 Bang 6: Tdn thuong phoi hop
Ton thUdng phoi hdp Gay xUdnq Tdn thUdnq qan. Id qan
Tonq
So trUdng hdp 11 10 21
o/o
32,4 44,2 76,6
Nhan xet: Sd benh nhan cd tdn thuang phdi hgp gay xuong. Id gan chiem ty le cao nhat 76,6 %. Ti le tdn thuong phdi hgp cao la bdi vi sd trudng hgp dugc tao hinh che phii nguyen nhan thudng gap do tai nan nen thudng cd gay xuong kem theo hay nhiing viing van ddng nhu cd ban tay hay cd ban chan la vimg ma ngay dudi da la gan va xuong nen khi tdn thuang mat da thi thudng kem theo tdn thuong gan va xuong.
Bang 7: Cac loai vat che phii khuyet hdng
Loai vat da Vat gan tay Vat bap chan trong
Vat dieu bay Vat lUng ke ngdn Vat hien cudng ngoai vi
Vat lien cdt sau Tdng
So trUdng hdp 2 4 5 5 13
3 32
o/o
6,24 12,5 15,63 15,63 40,6
9,4 100
Nhan xet: vat hiln cudng ngoai vi dugc sir dung nhieu nhat chiem ty le 40,6 %>.
Trong nghien ciiu cua chiing tdi cd 40,6% benh nhan chiing tdi da sir dung vat hiln cudng ngoai vi de che phu cd tdn thuong KHPM Id gan, xuong, khdp d 1/3 dudi cang chan, cd chan va vimg cii gdt. nghien eim ciia chung tdi phii hgp vdi nghien ciiu cua Vii Nhit dinh (2004) va M.P.Suri (2005) [1], [3].
Vat nhd nhit cd kich thudc 3x4cm, vat ldn nhit cd kich thudc 9x12 cm. Tai vi tri bdc vat cd 2 trudng hgp vat nhd chiing tdi ddng kin ngay, cdn 11 trudrig hgp chiing tdi ghep da tu than. Trong sd 13 vat dugc sir dung cd mdt vat chit hoan toan nguyen nhan la do tac mach, benh nhan nay cd the trang beo nen cudng vat tuong ddi day, qua trinh bdc vat cung khd khan hon. Mdt vat bi hoai tir 1/3 vat, mdt vat bi hoai tir mep nguyen nhan giai doan diu vat tuong ddi cang khdng xir tri kip thdi, cdn 10 vat song tdt liln da thi diu
Ngoai ra trong sd benh nhan nghien ciiu
chiing tdi cdn sir dung 15 vat dieu bay, vat lung ke ngdn, vat gan tay, vat lien cdt sau de che phii cac KHPM d mu tay, ngdn tay. Deu cho ket qua tdt, vat lien da ngay thi dau.
trong do 5 vat dieu bay che phii cho ngdn cai va 2 vat lien cdt sau che phii cho mu ngdn cai va ke ngdn 2-3 la phai ghep da chd lay vat, cdn 6 trudng hgp cdn lai thi ddng da true tiep. cac vat nay sir dung phu hgp cho vimg ban tay •vd chit lieu da tuong ddi phu hgp ca ve mau sac ciing nhu chiic nang ty de, cam nam.
Vat bip chan trong cudng mach lien dugc chi dinh cho nhiing KHPM d 1/3 tren cing chan va gdi. trong 4 trudng hgp chiing tdi sir dung vat nay cd 1 trudng hgp bi hoai tir mep vat do sau phau thuat chiing tdi diing den de sudi vat do de den hdng ngoai gan qua nen vat bi bdng, cdn 3 trudng hgp vat sdng tdt dap iing dugc ca ve chiic nang va tham my. day la vat cd giai phau tuong ddi
HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
hing dinh, vat chiing tdi lay ldn nhit la chan, khdp gdi, 1/3 dudi diii, ngoai ra vat cd 9xl3cm. cudng vat dai tir 6-17cm [2] nd dap thi sir dung dugc dudi dang cudng tu do.
img dugc cho khuyet hdng d 1/3 tren cang Bang 8: Xir tri tai vi tri bdc vat
~~~~~~~~---~~---___PPPT
Vat ^ — - _
Vat gan tay Vat bap chan trong Vat dieu bay Vat lUng ke ngdn Vat hien cudng ngoai vi Vat lien cdt sau Tong
Khau kin 2 1 0 5 1 0 9
Ghep da tU than 0
4 5 0 12
3 23
Tong 2 4 5 5 13
3 32
Ti le khau da kin d vi tri lay vat it bdi vi chi mdt sd trudng hgp lay vat da nhd thdng thudng dudi 5 cm ddi vdi vat hien va vat bap chan trong. Vat lung ke ngdn la vat ma sau khi lay cd the ddng da true tiep
Bang 9: Danh gia ket qua sdm trudc 3 thang
^ ^ ^ ^ ^ KQ TT ^ ^ ^ ^ ^
Vat ^ " ~ ^ ^ ^ Vat gan tay
Vat bap chan trong Vat dieu bay Vat lUng ke ngdn Vat hien cudng ngoai vi Vat lien cdt sau Tdng
Tot Vat song hoan toan
2 3 5 5 9 3 27
Vura Hoai tu' mep
vat 0 1 0 0 1 0 2
Xau Hoai tur 1/3 vat
0 0 0 0 2 0 2
Hoai tu*
toan bo vat 0 0 0 0 1 0 1
Nhan xet: cd 84,4%) dat kit qua tdt lien vet md thi diu. cd 2 trudng hgp dat kit qua vua trong dd cd 1 vat bap chan trong va 1 vat hien hai vat nay bi hoai tir mep vat. cd 3 trudng hgp ket qua xau dd la 3 vat hien, 2 vat bi hoai tir 1/3 vat, 1 vat bi hoai tir hoan toan ca bi hoai tir toan bd vat.
Nguyen nhan ciia vat nay bi hoai tir la do chen ep cudng da khdng dugc phat hien kip thdi, mat khac trudng hgp benh benh nhan nay beo nen khi bdc vat ciing khd khan hon, cudng day hon nen de bi chen ep
Bang 10: Danh gia tinh trang vat sau khi ra vien sau 3 thang
^ ^ - ^ ^ ^ KQ Vat ^ ^ ^ ^ . ^ ^ ^ Vat gan tay
Vat bap chan trong
Tot 2 3
VijTa
0 1
Xau 0 0
Y HOC VIET NAM THANG 10-SO 2/2010
Vat dieu bay Vat lUnq ke nqdn Vat hien cudnq nqoai vi Vat lien cdt sau Tdng
5 5 9 3 27
0 0 2 0 3
0 0 0 0 0 Trong 30 trudng hgp din kham lai sau 3
thang kham lai thi cd 90%) cho kit qua tdt con 10% trudng hgp cho ket qua vira, khdng CO ket qua xau. dieu nay cho chiing ta thay mgt sd nhiing uu diem ciia cac vat da can cd cudng mach lien dung de che phii cac khuyit hong phan mem, gia tri sir dung cao, miu sic vat ddng nhat vdi vimg xung quanh
V. KET LUAN
- Sd benh nhan bi tai nan giao thdng chilt^,ty le 46,9%), nam/nii la 4/1. Tai nan lao dgng li 28,1%) va toan bd la nam. Tai nan sinh hoat chiem 18,8%), nam/nii la 3/1.
- Khuyet hdng phan mem do vet thuong ldc, mat da la 53,1%), bdng sau 15,6%). loet dilm ty 18,8%, loet lau liln 12,5%.
- Khuyet hdng phan mem d chi tren chilm 40,6%), chi dudi la 59,4%.
- Sd benh nhan bi khuyet hdng phan mem cd kich thudc >6-15cm chiem ty le 62,5%, £5cm la 37,5%.
- Tdn thuong phdi hgp gay xuong la 52,4%, tdn thuong gan. Id gan la 47,6%).
- Che phii khuyet hdng phin mem bang vat Men cudng ngoai vi la 40,6%o, vat dieu bay 15,6%), vat lung ke ngdn 15,6%). vat bap chan trong 12,6%, vat lien cdt sau 9,3%), vat gan tay 6,3%).
Sd benh nhan dugc ghep da tu than tai vi tri bdc vat chiem ty le 71,9%, khau kin vet md la 28,1%.
- Miic do sdng ciia vat tdt chiem ty le 84,4%, vira 6,3%, xiu 9,3%.
- Danh gia seo sau khi ra vien tren 3 thang dat kit qua tdt 90%), 10%) kit qua vira
KHUYENNGHI
Nhiing benh nhan bi bdng sau nhit la d vimg khdp van ddng can din vien sdm dl cd chi dinh dieu tri dieu tri phu hgp tranh cac di chimg dang tiee.
Nhiing benh nhan bi tai nan lao ddng bi ldc mat da can den vien sdm de dugc phlu thuat kip thdi nham tranh nhung tdn thuong them nhiing td chirc khac nhu gan, xuong...
TAI LIEU THAM KHAO
1. Vu Nhat Dinh (2004), "Nghien cieu gidiphdu vd img dung lam sdng vgt da cdn hien ngodi hinh ddo cuong ngogi vi de dieu tri KHPM vimg 1/3 duai cdng chdn, co cJidn, mdt cd chdn vd cu got", Luan an Tien sy y hoc-Ha Ngi
2. Le Phi Long, Nguyen Tai Son (2007), "
Mot so dgc diem gidi phdu vd ung dung lam sdng vgt nhanh xuyen dong mgch bdp chdn trong" Tap chi Y hgc Viet Nam, chuyen de Phau thuat tao hinh.
3. Jose Antonio Garcia del Campo and etal (2008) "Local flap reconstruction of large scalp defects," Med Oral Cir Bucal vol 13, Nolo, Page: 666-670
4. M.P.Suri and et.al (2005) "Post-Traumatic posterior heel soft tissue defect
reconstruction". Indian J Plast Surg vol 38, No 2, Page: 138-142.
5. Youssef Saleh and et.al (2007) "A Suggested Algorithm for Post-Traumatic Lower Limb Soft Tissue Reconstruction."
Egypt, J.Plast.Reconstr.Surg vol 31, No l,page: 87-96.
