Y Hpc VIET NAM THANG 10 - SO DAC BIET/2011
OANH GIA KET QUA sCf DUNG VAT DA CAN MACH HIEN CUONG NGOAI VI DIEU TRj KHUYET HONG PHAN MEM
VUNG CANG CHAN VA GOT CHAN
Le Minh Hoang, Vu Due Chuyen, Dinh The Hung (*)
TOM T A T
Phau thuat chuyen vat co cuong mach che phii khuyet hong phan mem la mot phUdng phap dieu tri dupe thUc hien tai nhieu trung tam phau thuat. Tir thang 9/ 2007 den thang 8/2011, khoa Chan thUOng Chinh hinh Benh vien Viet Tiep Hai Phong co 24 benh nhan dUdc phau thuat chuyen vat da can mach hien cuong ngoai vi che phii khuyet hong phan mem viing cang chan, got chan. Ket qua 22 vat song tot, 1 bi hoai tir toan bp vat, 1 bi hoai tir mot phan vat, 18 benh nhan co ket qua cd nang rat tot va tot, 1 benh nhan co bien chimg chay mau sau mo.
ABSTRACT
From September 2007 to August 2011, at Viet Tiep Hospital, 24 defects of the soft tissue from to the leg and the heel of foot were traited by vasculars pedicuiates fascio-cutaneous flaps. We have had the following results: 22 healthy flaps, 2 necrotic flaps, 18 i patients who had good function of the limb, 1 complication.
I. OAT V X N OE
Khuyet hdng phhn mhm (KHPM) viing cing chan, got chan la mot t6n thuang gay 16 gan, mach mau va th^n kinh do nhieu nguyen nhan khac nhau. Day la t6n thuoTig thuang gap va viec di^u tri con gap nhieu kho khan, nhu vung khuylt hdng khong dugc che phu thi gan, xuong, mach mau thhn kinh se bi hoai tir anh huang nghiem trong dhn chirc nang di lai va sinh hoat cua benh nhan, c6 khi phai cat cut chi. Co nhi^u phuang phap dilu tri nhu ghep da tu do, sir dung cac vat hoac
cac tru da ma cheo chan, try da kicu Filatov,
\ al tu do bang ky thuat vi phau va cac vat co cuong mach lien. Mot trong nhirng phuang phop cir nhieu uu diem dugc cac tac gia trong
\ a ngoai nuac ap dung la sir dung vat da con CO cuong mach lien. Nam 1992, Masquelet A.C. do sir dung thanh cong vat da con co cuong mach lien a cang chan de che phii ton khmct da mat ngoai gut. C) Viet Nam, nam 2003 Vu Nhat Dinh va cong su da bao cao 99 vat da can hien ngoai cuong ngoai vi dugc sir dung de che phii cac KHPM vimg 2/3 duai cang chan va xung quanh khop co chan dat ket qua tot: 93 vat song hoan toan, 4 vat bi hoai tir mep vat va 2 vat hoai tir phai cat bo.
Tai khoa Chan thuang Chinh hinh Benh vien Viet Tiep trong thai gian tir thang 9/2007 dhn thang 8/2011 chung toi da dieu tri cho cac benh nhan bi khuyet hong phan mem vimg cang chan va got chan bang chuyen vat da can mach hien cuong ngoai vi va da dat dugc mot so ket qua buac dau tuang doi tot.
Bao cao nay nham muc tieu: Ddnh gid ket qud sir dung vat da cdn mach hien cudng ngoai vi dieu tri khuyet hong phan mem viing cdng chdn vd gdt chdn. Tir do dua ra mot so nhan xet ve chi dinh vd phieang phdp dieu tri.
II. 06l TaONG VA PHl/ONG PHAP NGHIEN COU 2.1. Doi tu'ong nghien cmi: cac benh nhan co cac khuyet hong phan mem vimg cang chan, got chan dugc phau thuat che phu
HOI NGHI KHOA HOC BENH VIEN HUTU NGHI VIET TIER HAI PHONG LAN THL/ 37
bang vat da can mach hien cuong ngoai vi lai khoa Chan thucmg Chinh hinh Benh vien
Viel liep Irong ihiri gian tir ihimg ^V2()()7 cicn thang 8/2011.
2.2. Phuong phap nghien ciiu: Mo t;i cat ngang
Tham kham IxMih nhan (lam siing \a can lam sang) dc xac djnh iigu\ en nhiin. ihiri gian. \i Iri, kich thucVc, linh chat cua Ion thucmg. benh ly loan than.
Chuan bi benh nhan: cat loc ky to chirc hoai tir. nhiem trimg lai nai nhan vat; xiic djnh \ i tri cho \ al \ a \ c sinh sach sc nai cho vat.
Phuang phap phau ihual:
+ Thiol ke \ a hoc \ al.
+ Chuan bi nai liep nhan \al: cat loc lai
\el thuang bi khuyet hong: lay bo to chirc hoai tir \ a to chirc xa seo.
+ Chuyen vat che phii vimg bj khuyet hong, khau co dinh vat.
+ Khau lai vet mo lay vat, ghep da mong tu than neu can.
Chirc ndng chi:
+ Cam miiu ky, dan luu.
- Theo doi va dieu tri sau phau thua iihaiii phiu hien ciic bien chirng sam de xiitr kip thcri nhu chay miiu, thieu mau nuoi vald(
di- vao cucMig vai, cang cucmg vat.
Ihco d(~)i dinh ky de danh gia ket qui phau Ihuat: sir song ciia vat. phuc hoi chut nang chi, Iham my ncri cho va nhan \at. sue chiu dung ciia \ at khi li nc^n.
Khc'mg bat dong khcrp; lap luyen som cho benh nhan IrucVc vii sau mo.
Phiin loai kcl qua Sir song cua vgt:
+ I c'n: Vat song hoiin toan, lam lanh lor thucmg.
+ Vira: Vat sdnu.. co hoai tir mot phan mcp vat gay \ iem ro phai can thiep bo sung.
+ Xau: Vai bi hoai tir loan bo. phai thao bo \'at.
Diem
0 1
2
3
Dau
Khong Khi gang sire keo
dai Lien tuc nhu'ng it
gay chii y
Gay trd ngai sinh hoat
i a n g 1 : T h e o phan do ciia T e r s c h i p h o r s t Van dong
khdp goi Binh thudng Gap90-120°
Gap < 90°, han che duoi
10°
Cirng khdp
Van dong khdp co chan
Binh thudng Khong gap dUdc mu chan
Bien dang chan ngi/a nhUng con cir dpng dUdc ban chan
Cirng khdp tU the ban chan ngua
Di budc mot Khong
Co
Di khap khieng
Khong Nhe
Nang
J Rat t6t:< 2d; Tot: 3d; Trung binh: 4d; Xau >5d.
III. KET QuA NGHIEN ClTU
3.1. Dac diem doi tuong nghien cuu:
Nguyen nhan ton thuang:
+ Tai nan giao thong: 19 + Tai nan lao dgng: 2
+ Thuang tich chien tranh: 2 "U + Viem hoai tir da: 1.
Giai tinh: 16 benh nhan nam va 8 benli nhan nii;
Tuoi tir 17 den 83.
Y HOC VIET NAM THANG 10 - SO OAC BIET/2011
Vi tri ton thuang:
+ Cang chan:
1/3 giira: 1 1/3 duai: 2 + Got chan: 20
+ Mom cut ban chan: 1 Tinh chat ton thuang:
+ Tinh trang nhiem ti-iing: co: 16. kliong: 8.
+ Tinh trang nhn khuyet h6ng: 16 gan got: 20; 16 xuong chin: 2; lo thdn kinh chay sau va gan got: 1; mat da mom cut: 1.
3.2. Ket qua dieu tri:
Ket qua gan: 3 tudn ddu.
Thai gian: tir khi bi ion thuang den khi phau thuat:
+ 1 luan: 14;
+ Tren 1 luan den 1 thang: 5
+ Tren 1 thang: 5. Benh nhan bj ton thuang lau nhal ducrc phau thuat:40 nam.
Thai diem phau thuat: mo co ke hoach sau khi \ao vien tir 1 luan den 3 luan
Phuc7ng phap che phii:
Vat da can mach hien cu6ng ngoai vi: 24
SU song cua vat SolUdnq
Ti le %
E
Tot 22 91,7
lang 2: Ket qua gan Vira
1 4,15
Xau 1 4,15
Tong cong 24 100
Ty le vat song t6t 22/ 24.
Ty le vat s6ng nhung co \iem do phai can thiep phau thuat 1 / 24 Ty le vat bi hoai tir: 1/ 24.
Ket qua xa: chi co 20 benh nhan dugc danh gia sau 3 thang, 6 thang va 9 thang.( 2 benh nhan chua du 3 thang sau m6, 1 benh nhan co hoai tir vat, 1 benh nhan bj cut ban chan khong danh gia ket qua xa)
Bang 3:
Chirc nang chi So lUtfng
Tile
Danh gia chuc Rat tot
17 85,00
nang chi theo tieu chuan ciia Tot
1 5,00
Trung binh 2 10.00
Terschiphorst Xau
0 0
Tong cong 20 100
Chuc nang chi tot va rat tot: 18/20.
Chuc nang chi trung binh: 2/20. Benh nhan khong gap dugc mu chan do co ngan gan got dugc phau thuat noi dai gan got.
- Thdm my nai cho va nai nhan vat: chi CO 10 benh nhan dugc danh gia sau m6 12 thang thiy seo mhm mai, khong co keo.
Sue chiu dung ti nen cua vat khi di lai:
do vat da can tuang d6i day, dugc nuoi duong tot nen khong gap bien chimg loet, tioai tu da do di lai.
IV. BAN LUAN
4.1. Dieu kien de vat song tot - Chudn bi tot nai nhan vgt:
Cac truang hgp bi khuyet hong phan mem do chan thuang den som truac 6 gia dugc m6 cap ciru cat loc ky t6 chuc dap nat ban, rira vet thucmg bang nuac oxy gia va dung dich NaCl 0,9%. Cac benh nhan den mugn dugc cat bo t6 chuc hoai tir, viem nhiem, dan luu mil. Sau mo benh nhan dugc
HOI NGHI KHOA HOC BENH VI^N HUfU NGHI VIET TIER H A I PHONG LAN THLf 37
diing huycl thanh man dang truang (NaCl 0,9%) lucVi uVrl lai cho lien luc dac bicl la khuNcl hong phan niC'm co Ig giin xucmg vii tiem khang sinh toim than cho den khi vi:l thuofng het nhiiMii Iriing, t6 chirc hat phiit trien loi mai thuc hien CIIUNCMI \al che phii.
Co 1 benh nhan hi \ iem hoai lir phan mem 16 gan dugc m6 chu>cn \at khi con viem gan, kcl qua \ at bi hoai tir phai cat bo.
Chudn bj nai cho vgt: kiem tra da viing nay co bat thucmg ha\ khong (\ iem nhiC-in hay CO seo cu). \c sinh sach sc IrucVc m6.
Thiet ke \al sc sir dung.
- Phdu thudt: I,a\ \al dii rc)ng dc che phu, \i\\ cu6ng dii dai dc xoay \ at, tao ducrng ham de dat cu6ng \'al. Dua theo phuc^ng phap cai tien ciia Hyakusoku va cgng su [8], Vu Nhat Dinh [2], chung toi sir dung toan bo vat CO dai da tren cuong de lam rong them duong ham chua cuong tranh dugc bien chirng phii ne, chen ep cuong. Trong qua trinh phau thuat khong lam ton thuang mach nu6i vat, khong lam cang cuong vat, cam mau ky. dan luu hut lien tuc kieu Redon lay het mau tu va dich de dam bao nguon nuoi duong \ai t6t tranh u tre tuan hoan.
- Theo doi vd cham sdc sau mo:
Theo doi mau sac, nhiet do, tinh trang phii ne, chay mau a mep vat chu yeu trong 24 gia dau. Thay bang hang ngay, dat chan tu the phii hgp tranh de cjp vao cu6ng \al.
- Phat hi$n va xir tri bien chung kjp thai:
cac bien chung co the gap la tac mach, chay mau, nhiem triing. Chiing toi gap 1 truang hgp bien chimg chay mau sau mo chuyen vat hien cuong ngoai vi che phii khuyet h6ng viing cu got, gan got phai phau thuat lai dh cam mau dat ket qua vat sdng tdt. Co 2 benh nhan bj hoai tu mep vat dugc m6 cat lgc t6 chiJC hoai tu va dat kht qua t6t. Hai vat bi hoai tu vat do tac mach nuoi duong phai cat
b(), do cuong vat ngan bi cang va nhiem Iriing sau mo.
4.2. Dieu kien dc phuc hoi chirc nang chi tot
Phau thuiil va dieu tri sau phau thuat dong vai tro quyct dinh dc phuc hoi cho chiic nang di lai cho benh nhan:
( ill bo het to chuc xo seo quanh viing khuyet hong;
Cu6ng vat du dai de kh6ng bi anh hucVng khi benh nhan \ an dgng khc3fp;
Diim biio \ cl mo lien nhanh, khong bj nhiem triing, s?o mem mai;
Khong bat dong khcrp co chan sau mo;
Tap luycn iruoc \a sau mo: ngay sau khi hi thuang benh nhan thuang dau nhieu ncn khong van dgng. ban chan a tu the gap gan chan, dc lau co nguy co cung khcip tuthe ban chan ngua do co gan got. Vi \ay benh nhan can dugc tap van dong thu dgng roi den chii dgng cac khcjp ciia chi bi ton thuang dac biet la khap co chan. Viec tap luyen phai dugc tien hanh scrni \ ii deu dan. keo dai;
Phau thuat noi dai gan got neu benh nhan bi co ngdn gan got sau chuyen vat va dieu Iri bao t6n khong ket qua.
V. KET LUAN
Qua 24 benh nhan bi khuylt hong phan mhm viing cang chan \ a got chan dugc phau thuat che phii bang \ at da can co cuong mach nuoi chung toi co dugc ket qua buc^c dau: 22/
24 vat s6ng tot, co 1 vat bi hoai tu mot phan mep vat va viem ro, 1 benh nhan bi hoai tit vat da can mach hien cuong ngoai vi; 18/20 benh nhan dugc theo doi tren 3 thang co ket qua ca nang rat tot va tot, 2 benh nhan co ket qua CO nang trung binh, khong c6 benh nhan bi mat co nang chi, 1 benh nhan c6 bien chung chay mau sau mo.
Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
Mgt so nhan xet: 3.
Chi dinh dieu tri:
Lua chgn vat: khuyet h6ng phan mhm vung cang chan, got chan 16 gan xuong co the chgn vat da can mach hiln cu6ng ngoai vi 4.
de che phii.
- Thai diem phau thuat: phau thuat cap cuu de cat lgc to chuc hoai tir; chi phau thuat chuyen vat khi tinh trang viing khuylt hong
het nhiem triing, kh6ng co t6 chirc hoai tii'. 5.
Phirang phdp dieu tri:
- Chuan bi t6t noi nhan vat. noi cho vat;
Ton trgng tu\et d6i mach nu6i vat:
cuong du dai va rong, vat du de che phii khuyet gan, xuong. mach. than kinh;
Theo doi cham soc benh nhan sau mo:
phat hien va xir tri kip thai cac bien chung. 6.
Phuc hoi chirc nang scjm truac va sau phau thuat.
TAI LIEU THAM KHAO
1. Vu Nhat Dinh, Nguyen Tien Binh. Nghien V.
ciru, iimg dung vkt da can hien ngoai cuong ngoai vi dieu trj cac khuyet hong phan mem vung 2/3 duoi c4ng chan va xung quanh co
chan. Y hgc Viet Nam s6 dac biet Thang 8.
10/2003. Trang 3 6 - 4 1 .
2. Nguyen Tien Ly, Nguyen Tien Binh. Ket qua ung dung cac vat co cuong mach lien de
dihu trj khuyfit hong phSn mem viing 1/3 9.
duai cing chan, c6 chan, got chan, ban chan.
Cong trinh nghien ciiru Y hgc Quan su, so 3, 1998, Uang 51-55.
Nguyen Dang Nhat: Che phii khuyet hong phSn mem viing cang ban chan tai Benh vien Trung uong Hue. Y hgc Vicl Nam so dac biet
Thang 10/2003, trang 172 182.
Nguyen Thai So'n: Dieu tri khuyet hong phan mem viing co chan, han chan va got chan bang dao da can co cuong mach bap chan. Y hgc Viet Nam so dac biet Thang
10/2003, trang 161 167.
Nguyen Xuan Thuy, Tru'ong Xuan Quang:
Buoc dau nghien ciru phau thuat chuyen vat da - than kinh hien cuong dau xa trong dieu trj cac khuyet hong phan mem vimg quanh got va cci chan. Y hgc Viet Nam so 7 - 2001, Chuyen de Chan thuong Chinh hinh, trang 44 -48.
Benhami A., El Mazouz S., Garib N., Oufkir A., Benzzou S. Le lambeau fasciomuculocutang de jambe. A propos de 9 cas cliniques. Annales de chirurgie plastique esthgtique. 2003, Vol 48 (3), pp. 173-179.
Godina M. Early Microsurgical reconstruction of complex trauma of the lower extremities. Plast. Reconstr. Surg.
1986, Vol 100, pp. 355 363.
Hyakusoku H., Tonegawa H., Fumiiri M.
Heel coverage with a T - shapped distally based sural island fasciocutaneous flap. Plast.
Recontr. Surg. 1994, 93: 872- 876.
Masquelet A. C , Romana M.C. Skin island flap supplied by the vascular axis of the sensitive supeficial nerves: Anatomic study and clinical experience. Plast. Recontr. Surg.
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