NGOAI KHOA — SO 2/2009
DANH GIA KET QUA DIEU TRI KHClP GIA THAN XUONG CHAY BANG DINH SIGN CO CHOT VA GHEP XUONG TlT THAN
TAI BENH VIEN VIET DlTC
\.' Ji } I I'
OAT VAN OE
Khdp gia than xuong dai chi dudi ndi chung, khdp gia than xuong chay ndi rieng la mot biS'n chiing nang ne sau di6u tri gay xuong, nd anh hudng rat Idn d6'n chiic phan ciia chi thi va cha't lugng cugc sdng ngudi benh. Tai Khoa PT Chan thuong chinh hinh- Benh vien Viet Diic khdp gia than xuong chay chid'm ty 16 khoang 70,42% [1] vdi cac phuong phap dieu tri bang nep vit, dinh ndi tuy, kem ghep xuong tu than, xuong ghep chii yeu la'y tir xuong canh chau. Cac ky thuat tren da dugc cac tac gia danh gia va tdng k6't trong cac cdng trinh khoa hoc da dugc bao cao [1,2]. Ridng ky thuat dieu tri khdp gia than xuong chay bang dinh SIGN thi chua cd tac gia nao tdng ket. De danh gia mot each tdng quat va toan dien v6 diiu tri khdp gia than xuong chay bang dinh SIGN va ghep xuong tu than chiing tdi tien hanh nghien ciiu di tai 'i)dnh gid ket qud dieu tri khdp gid thdn xUffng chay bang dinh SIGN cd chdt vd ghep xuong tu thdn ". Nham muc ti6u:
1. Danh gia ke't qua di6u tri khdp gia than xuong chay bang dinh SIGN va ghep xuong tuthan.
2.Ky thuat md va nhan xet mdt sd yg'u td anh hudng den ket qua di6u tri
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Nguyin Xuan Thiiy*, Tran Van Dung**, Liru Danh Huy*, Duong Dinh Toan*
lUf . :Il5_'
001 lapNG VA PHUONG PHAP NGHIEN ClfU
1. Ddi tuong nghien curu
Chiing tdi t\€n hanh nghi6n ciiu 60 BN khdp gia than xuong chay dugc dieu tri ket hgp xuong bang dinh SIGN va ghep xuong tu than tit thang 3 nam 2005 den thang 6 nam 2008.
2.Phuong phap nghien curu .<
- Md ta lam sang hdi ciiu va tien ciiu - Phan loai khdp gia theo Judet, Muller [3], [5]
- Danh gia kS't qua theo ti6u chudn cua Ter schiphorst [6]
3«Ky thuat dieu tri khdp gia xuong chay bang dinh SIGN va ghep xuong tu than
* Dinh SIGN (Surgical Implant Generation Network) [4] la mdt dinh kim loai cd ca'u tao dac biSt, rat ciing, tro v6 mat sinh hoc khong bi thai loai va la mdt dinh trdn dac. Dinh cd cac cd dudng kinh khac nhau tii 8mm den 13 mm. Chieu dai tir 200 den 420 mm. DSu trfin cong tao vdi than dinh mdt gdc 11°. Mdi dSu cd hai Id de chdt dinh. Diu tren cd mdt Id trdn, mdt Id bSu due. Dau dudi cd hai Id bau due. Tac dung ciia thiet ke dac biet tren la tao do di ddng nhat dinh theo true ciia than xuong va do ep
*Khoa PhSu thu$t chan thuong - chinh hinh, BV Viet Ddc
**Benh vien da khoa NghTa Dan - Nghe An v i f f i n
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NGOAI KHOA — SO 2/2009
'r,J: i U
giiia hai dSu xuong gay.
- Vit chdt: vit chdt cd cac dudng kinh khac nhau giira dau xa va dau gSn, lam chdt khdng bi trdi theo chieu tid'n, chi6u dai ciia chdt tir 25-75mm.
* Chi dinh phdu thuat
Cac trudng hgp khdp gia (KG) than xuong chay.
* Chdng chi dinh
Khdp gia nhiSm triing.
Phan mim tren d KG khdng dam bao. .^' r' :i-j^ • • m.'.;- •..'•• : -w ''-'
* Dudng md • . r ;i> u .: . Neu ngudi benh cd seo md cii thi di theo seo md cu, nd'u la md ISn dSu thi dudng md la dudng trudc ngoai cang chan. BN nam ngira hoac nam nghieng. Dat ga rd diii xoay cang chan vao trong. Rach da mat trudc ngoai cang chan, phia ngoai mao chay khoang 2 cm. Keo cac co ra ngoai bdc Id mat ngoai xuong chay dudi mang xuong.
* Con phuang tien ket hop xuang (KHX): Tien hanh la'y bd phuong tien KHX cii..
* Ket hap xuang dinh SIGN: lay bd td chuc xo, doa dng tiiy, ddng dinh xudi ddng, bat vit chdt (1 hoac 2 vit tiiy trudng hgp cu
thi) . . n r - ••.:• i v ,
* Lay xuang ghep (la'y d xuong mao chau): Rach da each mao chau 2cm, dai chiing 10 cm, rach can vao xuong canh chau.
Xuong xd'p ghep cd the la'y bang kim gam xuong hoac bang due cong va cat ra nhiing manh nhd cd kich thudc 15mm x 5mm x
5mm. '[ '• ><. '! • ' . ; ! •' "•'' ' < '^'^ •'• '
* Ghep xuang Cac manh xuong mdng dugc ap sat vao thanh xuong dudi mang xuong bac cdu qua d gay tit dSu ben nay den dau ben kia theo phuong phap Phemister.
Nhiing khe hd thi diing miu xuang xd'p nhdi kin vao theo phuong phap Matti. Ki^m tra do viing ciia d gay va cac manh xuong ghep.
KET QUA VA BAN LUAN
1. Ket qua chung :
- Ket qua tdt: 41 trudng hgp, chid'm 68,3%
- K6't qua kha: 16 trudng hgp, chi6'm 26,7%
- Trung binh: 2 trudng hgp, chiem 3,3%
- Ket qua xa'u: 1 trudng hgp, chid'm 1,7%.
2. Bien churng va phuc hoi chiifc nang sau mo
- Khdng cd trudng hgp nao nhilm khudn v6't md.
- Tu mau va ne vet md cd 2 trudng hgp.
- Cling khdp gdi cd 1 trudng hgp (1,7%), Cling khdp cd chan 3 trudng hgp (5%).
- Teo CO (cang chan) viia va nang cd 4 BN (8,4%).
- Ngan chi (>3 cm) cd 7 BN (11,7%).
- Dau tai chd lay xuong ghep 5 BN (11,11%)
3. Ky thuat mo: ,^„.f|j
* Chi dinh dieu tri. ..i ,\w,
- Tat ca cac loai khdp gia xuong chay the phi dai va xo teo (theo each phan loai ciia Judet) khdng cd nhidm khudn va cac ky thuat dieu tri khac bi that bai.
- Phan m6m ciia cang chan trong gidi ban cho phep, khdng cd tinh trang viem nhi6m tren da trudc khi phau thuat. Dac bi6t phai dam bao che phii dugc xuong sau phau thuat.
28
NGOAI KHOA — SO 2/2009
* Ky thuat dieu tri.
- Phai cat bd h6't td chiic xo chen vao giiia hai dSu xuong va bao boc xung quanh khdp gia.
- N6'u hai dSu xuong cd hien tuong chai xuong (sclerose) phai gam bd doan xuong dd d6'n khi nao ma hai dSu xuong cd rdm mau .
- Phai khoan rdng lam thdng hai dSu dng tuy thudng bi bit do td chiic xo hoac td chiic xuong.
- Kidm tra ky true ciia chi, chieu dai ciia chi (so vdi ben lanh) trudc khi quye't dinh lap dat cac chdt ngang.
- Kich thich hai dau xuong gay bang td chiic xuong ghep, nhimg manh xuong ghep nay phai dugc cd dinh chac chan vao d gay.
- Nhiing BN cd KG phi dai do bat ddng khdng vOng chac, cai xuong siii to, trong md cd th^ la'y tii phdn cai siii nay de ghep n6'u cam tha'y ghep dii.
4. Mot so' yeu td anh hudng den ket qua dieu trj :
- Ke't qua md khdng lien quan dd'n vi trf 6 gay. (•v:;.>n q j.; Wi
i,rj - Lien quan ke't qua dieu tri theo loai gay xuong trudc khi dan den khdp gia : 0 nhdm gay kin cho ke't qua tdt la 70,4%,
nhdm gay hd la 66,7%
- Lien quan theo phan loai khdp gia :Khdp gia phi dai cho kd't qua tdt la 64,7% ,khdp gia xo teo la 73,1%( khdng cd y nghia thdng k6).
- Li6n quan theo nhdm tudi : 0 nhdm tudi 15-30 ket qua tdt cao nhat (85,5%) so vdi cac nhdm tudi 31-50 la 57,1% va nhdm tudi >50 la 45,5%. Su khac biet nay cd y nghia thdng k6 vdi p<0,05.
- Li6n quan theo gidi : Khdng cd sU khac biet giira hai gidi vdi p<0,05.
- KhOng cd mdi liSn quan giiia thdi gian tu: liic tai nan den khi phSu thuat khdp gia.
- Khdng cd mdi lien quan giiia cac phuong phap ke't hgp xuong dSn den khdp gia.
- \\y.- VvV n:! v.i'.W \y.y: "!\,<\i, U\
KET LUAN
Dieu tri khdp gia than xuong chay bang dinh SIGN va ghep xuong tu than la mdt phuong phap cho ke't qua lien xuong cao : vdi ket qua tdt va kha chie'm da sd (95%), miic dd ddi hdi ky thuat khdng qua khd. Cd th^ ap dung tai cac benh vien tuye'n tinh
"J>"" ' f j i i i i r i,j -juij!! 3iu::.>Dq
29
NGOAI KHOA — SO 2/2009
Trudc mo Sau mo 2 ngay Sau mo 1 thdng Sau mo 3 thdng
f l O l i / . '
Ket qua trudc va sau mo cua mot benh nhan
tatli.
TAI LIEU THAM KHAO d'.> '^ndri}?
1. Hoang Van Chien (2004), Nghien cicu dieu tri khdp gid thdn xUong ddi chi dual sau chan thuong hang kit hap xuang nep vit va ghep xuang tu thdn, Luan van thac sy y hoc, Dai hoc Y Ha Noi.
2. Nguyin Dure Phiic, Nguyin Trung Sinh (2001), Gido trinh ngoqi dai cuong phdn chan thuong chinh hinh, tap VII thang 2, Tr
103-131. 7 3. Judet,R, and Patel, A (1972), "Muscle
pedicle bone grafting of long bone long
osteoperiosteal pericorticartion". Clin.Orth.
Vol 87 ;74 -84
4. Lewis G. Zirkle (2005), Technique Manual of SIGN IM nail Insertion and Extraction- SIGN tibia Nailing technique pp 9-21
Muller M.E, Thomas J.R (1979),
"Treatment of nonunion in fracture of long bone". Clin.Orthop. 138; 141-146
Ter Schiphorst P (1987), "Fractures et Pseudarthroses de jambe traitees par fixateur d'Hoffmann en cadre. Bilan informatiqeu de 200 cas sur 17 ans d'experience", These medecine, Montpellier.
5.
6.
