Nghien cifu khoa hpc
Thay doi mat dp xifdng giai doan sdm xung quanh 6 coi nhan tao sau thay
khdp hang toan phan khong xi mang
ThS. Dao XuSn Thanh*, Bs. Trin NguySn Phuong*, PGS.TS. Nguyin Tie'n Binh**
TOM
TATChij 6k Thay ddi mat dp xuong xung quanh 6 edi khong xi mang giai doan sdm. D61 ttfonq va phuang phap nghien cdu: 26 bpnh nhin vdi 33 l<hdp hang toin phin khong xi mang dugc thay tai khoa Ngoai benh vien Bach Mai tien tuc tCr 7/2008 din 2/2009. Phuong phap nghien ciiu mo ta cat ngang co ddi ctiiing. ChUng toi sur dung phuong phip DEXA di do mat dp khoang xuong xung quanh 33 6 edi khong xi ming. Ke't gua; Sau pliiu thuit 3 thing co su giam mat dp xuang quanh 6 edi nhin tao 5,2%.
Mat dp xuong tai cic vung 1, 2vi 3 quanh 6 edi theo phin chia cua DeLee co su thay ddi theo ctiiSu hudng giam tuong iing 12,14%, 4,6%, 1,86%. K6t luan; Mat dp xuang quanti 6 edi khong xi ming diin biin theo chiiu hudng giam sau 3 thing.
TU khoa: thay khdp hing toin phin, mit dp xuang.
I. DAT VAN DE
Thay khdp hang toln phSn (TKHTP) khong xi mang bat dau phlt triin tir thap ky 70 cua the ky trudc, cho din nay khdp blng toan phln khdng xi mang ngly dugc eli tiSn vdi nbilu tbilt k l khac nhau, vat lieu khac nhau nham muc dich keo dii thdi gian sir dting khdp, cai thien chit lugng cude sdng cho benh nhan. Dii cd su khlc nhau ve kieu dang vl chat lieu nhung sau TKHTP sinh ly truyen tai luc qua khdp hing dSu bi thay ddi. Binh thudng luc traySn qua d edi, qua sun khdp hing, cbdm xuong diii qua cic be xuong chiu lire tdi vd than xuong did [2]. Sau TKHTP luc traySn qua vd d edi nhan tao, chom va chudi khdp tir phia trong long ong tuy ra phia vd than xuong diii. Theo dinh luat
•Wolff xuat hien cac viing tang sinh xuong hoac tieu xuong quanh khdp nhan tao tiiy theo luc ty nen ciia phan khdp nhan tao tic dgng len phSn
* Khoa Ngoai - Benh vien Bach Mai
** Hgc Vien Quan Y
xuong liSn k l [7]. Mat do xuang xung quanh khdp nhan tao khdng xi mang cd anh budng Idn den thdi gian thay lai khdp. Mat do xuong bi giam lien tuc se dan den bien tugng long khdp v l benh nhan c6 thS se phii thay lai khdp nSu cle bien pblp diiu tri ndi khoa nhu diing tbudc biphosphonate khong mang lai kit qua mong mudn, do dd cac benh nhan sau md thay khdp blng nhan tao thudng dugc theo ddi mat do xuong quanh khdp d l cd the phlt hien vl diSu tri sdm giam mat do xuong [4]. De theo ddi dien bien thay ddi xuong xung quanh khdp blng nhin tao cd t b i dua vao muc dd phln tich giira khdp nhan tao v l xuong trSn X-quang thudng, do mat do xuong xung quanh khdp hang nban tao bang miy DEXA do hap thu tia X nang lugng kep (Dual Energy X-ray Absorptiometry), do khdi lugng xuong bang chup cat Idp vi dnh (Quandtadve Computer Tomography), do khdi lugng xuong bang chup cdng hudng tir
DIEN DAN Y HOC
Nghien cu'u khoa hoc
(Quantitadve MRI), do hip thu cbSt phdng xa radiophosphate. Phuang phip DEXA hay dugc sir dung nhat vi do chinh xac cao, thuan tien, it xam lln va re tiin [5], [10], [13].
Muc tiSu nghiSn cuu: Tim hiSu su thay ddi mat do xuong quanh d edi sau TKHTP khdng xi mang giai doan sdm sau phau thuat 3 thing.
II. DOI mm VA PHU^ITNG PHAP NGHIEN CIIU
1. D6i tinmg nghien cmi:
- Nhdm nghien cuu: 33 khdp blng toln phln khdng xi mang ciia 26 benh nhan da dugc thay tai khoa Ngoai Benh vien Bach Mai liSn tuc tir thing 7/2008 din thing 2/2009.
- TiSu chuan chgn benh nhan: cic benh nhan su dung ciing mgt loai khdp blng toln phSn khdng xi mang vdi d edi Trilogy (Zimmer, USA) loai dSu chuSn phu sgi hgp kim titanium (Ti-6A1-4V).
Hinh 1. 6 edi Trilogy kiiu tieu chudn - Khdng cd tai biSn v l bien cbung trong va sau phau thuat nhu vd xuong d edi, nhiSm triing...
- Nhdm cbung: Mat do xuong ciia khdp blng bSn ddi dien hoac cot sdng (cho cle tradng hgp thay c l 2 khdp blng) dugc coi nhu la nhom chirng de theo doi mat do xuong ciia benb nhan.
2. Phuxmg phap nghien cuu: nghien cuu mo ta cat ngang co ddi chiing
Phuong phdp thirc hien
- Sau phau thuat 7 ngay benh nhan dugc do mat do xuong xung quanh d edi nhan tao theo phan viing d edi ciia DeLee JG vl John Charnley.
- Mat do xuong ciia cd xuong dui bSn ddi dien hoac cdt sdng that lung ddi vdi cle benh nhan thay ca hai khdp blng, dugc do ciing thdi diim do mat
VCing II
Hinh 2. Phan vdng thay doi xuong quanh 6 edi theo DeLee vd John Charnley
do xuong quanh khdp blng nhan tao.
- Sau phau thuat 3 thing benh nhan dugc do mat do xuong kiim tra lai cung theo phuang pblp nhu trSn.
Ky thudt do
- Phep do do mgt ky thuat viSn chuySn khoa dam nhiem bang miy do mat do khoing xuong (Bone Mineral Density-BMD) DEXA HOLOGIC Explore phiSn bin 12.6.1.
- Ddi tugng nghien ciin nam ngira trSn ban do, hai chan dudi tbSng. MIy do tu ddng chuyen dich trong vung can do va tu ddng lua chgn cle thdng so. Muc do sai sd tdi da ciia miy II 1%.
- Ky thuat viSn sau dd thue hien phep do mat do khoing xuong xung quanh d edi nhan tao trSn miy vi tinh. Phan kim loai trong viing do se dugc tu dgng loai trir.
- Ket qui dugc tinh bang lugng khoing tren don vi dien tich (g/cm^).
Hinh 3. Do mat do khoang xuong quanh6coi
khong xi mdng
So 44 (Thang 09/2009) Y HOC LAM SANG I 3 5
Nghien cii'u khoa hpc
III. KET QUA
1. Dac diem ehung vl tudi va gidi tinh: 26 benh nhan tudi tir 19 den 69, tudi trang binh la 45,2±10,4.
Nam 17 (65,4%), nu 9 (34,6%). Ty le nam/nQ la 1,89.
2. Thay ddi mat do xmmg xung quanh d coi nhan tao
BMD trung binh Viing 1 Viing 2 Viing 3 To'ng
Sau 7 ngay 0,972±0,229 1,110±0,250 0,807±0,223 0,920±0,196
Sau 3 thang 0,851±0,191 1,056±0,233 0,790±0,180 0,869±0,176
Mirc giam 0.118±0,122 0,051±0,136 0,015±0,108 0,048±0,074
Ty le giam % 12,14%
4,6%
1,86%
5,2%
P p<0,001
p<0,05 p>0,05 p<0,001
Nhqti xet: Mat do xuong xung quanh d coi sau phau thuat 3 thing cd xu budng gilm vdi ty IS giam khoing 5,2%. Viing 1 giam nhieu nhat vdi ty le 12,14%, vdng 2 giam 4,6%. Viing 3 gilm mat do xuong rat it 1,86% va su khlc biet khdng cd y nghia thdng kS, tuc la khdng cd sir thay ddi nhiSu mat do xuong tai viing 3.
3. Thay doi mat do xmmg ciia nhom chiing
Mat do xuong cua 26 cd xuong dui ddi bSn thay khdp vl 7 cdt sdng that lung dugc do vio thdi diSm sau phau thuat 7 ngly vl sau 3 thing.
B M D cbung
Sau 7 ngay 0,755±0,142
Sau 3 t h i n g 0,749±0,136
M u c giam 0,009±0,055
T y l e giam %
1,2%
P p>0,05
Nhan xet: mat do xuong ciia nhdm cbung cd mirc do giam rat nhd vl su khlc biet khdng cd y ngbTa thdng kS. Nhu vay sau 3 thing khong cd su tbay ddi mat do khoing xuong cua khdp hing bSn ddi dien hoac cdt sdng cua benh nhan.
Khdng cd su khlc biet vS miic giam mat do xuong xung quanh d edi giiia hai nhdm nam va n&, tuong iing II 0,061 ± 0,076 d nam vl 0,033 ± 0,069 d nir (p>0,05)
Gidi
M u c g i l m B M D q u a n h d coi
N a m 0 , 0 6 1 ± 0 , 0 7 6
Nir 0 , 0 3 3 ± 0 , 0 6 9
P p > 0 , 0 5
IV. BAN LUAN
Qua nghiSn ciru quan sat dugc chiing tdi nhan thay rang mac dii khdng cd sir thay ddi mat do khoing xuong trong nhdm cbung (khdp blng ben ddi dien hoac cdt sdng ciia benh nhan), khdng cd sy khlc biet ve thay ddi mat do xuong giiia nam vl nii, nhung cd sy thay doi theo chieu hudng giam mat do khoing xuong quanh d coi nhan tao trong 3 thing dau sau TKHTP kbdng xi mang, ddng thdi tai 3 viing theo DeLee quanh d edi nhan tao cd sy thay doi khlc nhau vS mat do khoang xuong. DiSu nly chiing to cd sy anh hudng ciia phau thuat thay
khdp blng va khdp nhan tao din mat do xuong.
Cd 2 hien tugng cd the anh hudng din su thay ddi nly. Thir nhat II qui trinh lien xuong va su phlt trien ciia xuong ISn bS mat khdp nhan tao. Thu hai II thay ddi co sinh hgc ciia khdp hang nhan tao ddi vdi xuong quanh d coi (retroacetabular stress shielding) [9], [11].
Qui trinh liSn xuong dien ra theo 3 giai doan:
giai doan viem vd khuan xay ra vai gid cho din 1 tuan sau md; giai doan sira chira hinh tblnb chit dem collagen va tii tao mach mlu dien ra trong 4 dSn 6 tuln tiep theo va tiSn tdi hinh thanh can
DIEN DAN Y HOC
Nghien cii'u khoa hpc
xuong mim; giai doan phuc bdi keo dai tiip theo cho din vai nam hinh tblnb td chirc xuong mdi.
Do ciing chic cua td chirc xuong mdi thudng dat dugc sau khoang 3 dih 6 thing. Diiu nly phu hgp vdi sy gilm mat do xuong tdng the xung quanh d coi nhan tao trong 3 thing dau. Thay ddi co sinh hgc khdp blng vdi sy thay ddi Ip lyc khlc nhau ISn cic viing cua d edi d l dan dSn thay ddi mat do xuong tai 3 viing theo phan loai cua DeLee. CIc tic gia khlc cung cd kSt qua tuong tu trong 3 thing dau, tuy nhiSn mat do xuong tai cic viing se tiep tuc thay ddi theo thdi gian [8], [12], [13], [14].
Hinh 4. Mo td tdc dung luc khde nhau len phdn xuong lien ke 6 coi nhdn tao
NghiSn cuu nay cua cbung tdi chi dua ra kSt qui thay doi sdm mat do xuong quanh d coi nhan tao khong xi mang giai doan 3 thing sau phau thuat. Cac thay ddi nly can dugc tiSp tuc theo ddi trong cle giai doan tiSp theo 6 thing, 12 thing v l liSn tuc blng nam sau phau tbuat nham muc dich phlt hien sdm va diSu tri tiSu xuong quanh khdp nhan tao, keo dii tudi thg khdp v l cii thien chat lugng cuge sdng cho benh nhan. Phuong phap DEXA la mdt phuong pblp tuong ddi re tiin, chinh xlc, it xam lan, cd the sir dung d l theo doi diin biin mat do xuong v l cd thii do diiu tri phii bgp cho timg benh nban.
V. KET LUAN
Mat do xuong xung quanh d edi nhan tao sau thay khdp blng toln phan khdng xi mang cd xu hudng giam trong giai doan sdm 3 thing sau phau thuat.
TAI LlfUTHAM KHAO
1. Nguyen Tien Binh. Nhan xet ve sii dung khdp hdng khong xi mdng loai AML tai benh vien Trung uong quan ddi 108. Hoi nghi thuang nien hdi CTCH TPHCM 2004.
2. Nguyen Vdn Quang. Sinh co hoc khdp hdng. Hoi nghi thudng nien hoi CTCH TPHCM 2004.
3. DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976 Nov-Dec;(121 ):20-32.
4. Edward M Schwarz, R John Looney, Regis J OKeefe.
Anti-TNF-a therapy as a clinical intervention for periprosthetic osteolysis. Arthritis Res 2000, 2:165-168.
5. John M. Wright, Paul M. Pellicci, Eduardo A.
Salvati, Bernard Ghelman, Mathew M. Roberts, and Jason L. Koh. Bone Density Adjacent to Press-Fit Acetabular Components A Prospective Analysis with Quantitative Computed Tomography The Journal of Bone and Joint Surgery 83:529 (2001).
6. Kalfas IH. Principles of bone healing. Neurosurg Focus. 2001 Apr 15;10(4):E1.
7. Kushner A. Evaluation of woljfs law of bone forma- tion. J Bone Joint Surg Am. 1940;22:589-596.
8. Laursen MB, Nielsen PT, Soballe K. Bone remod- elling around HA-coated acetabular cups: a DEXA study with a 3-year follow-up in a randomised trial Int Orthop. 2007 Apr;31(2j:199-204. Epub 2006 Jun 8.
9. Pitto RP, Bhargava A, Pandit S, Munro JT.
Retroacetabular stress-shielding in THA. Clin Orthop Relat Res. 2008 Feb;466(2):353-8. Epub 2008 Jan 10.
10. Pitto RP, Mueller LA, Reilly K, Schmidt R, Munro J.
Quantitative computer-assisted osteodensitometry in
So 44 (Thang 09/2009) Y HOC LAM SANG I 3 7
Nghien cdu khoa hpc
total hip arthroplasty. Int Orthop. 2007Aug;31(4):431- 8. Epub 2006 Oct 17.
11. Schmidt R, Pitto RP, Kress A, Ehremann C, Nowak TE, Reulbach U, Forst R, Miiller L. Inter- and intraob- server assessment of periacetabular osteodensitometry after cemented and uncemented total hip arthroplasty using computed tomography.Arch Orthop Trauma Surg. 2005 Jun;125(5):291-7. Epub 2005 Apr 21.
12. Shetty NR, HamerAJ, Kerry RM, Stockley I, Eastell R, Wilkinson JM. Bone remodelling around a cement- ed polyethylene cup. A longitudinal densitometry
study. J Bone Joint Surg Br 2006 Apr;88(4):455-9.
13. Wilkinson JM, PeelNF, Elson RA, Stockley I, Eastell R. Measuring bone mineral density of the pelvis and proximal femur after total hip arthroplasty. J Bone Joint Surg Br. 2001 Mar;83(2):283-8.
14. Yousef Abu-Amer, Isra Darwech, John C Clohisy.
Aseptic loosening of total joint replacements:
mechanisms underlying osteolysis and potential therapies. Arthritis Research & Therapy 2007, 9 (Suppl 1):S6 (doi: 10.1186/ar2170).
SUMMARY
EARLY CHANGE OF BONE MINERAL DENSITY AROUND CEMENTLESS CUPS IN TOTAL HIP ARTHROPLASTY.
Objective: This study was designed to investigate bone remodelling around the cup in cementless THA.
Method: Thirty three standard porous coated Trilogy press-fit cups (Zimmer, USA) of 26 patients under- went THA were included, the nonoperated contralateral side or lumbar spine was used as the control Periacetabular bone density changes were assessed using DEXA. Results: Total BMD around cementless cups loss 5,2%. The BMD decreased significantly in DeLee zones 1, 2 and 3 by 12,14%, 4,6% and 1,86%
respectively. Conclusions: We observed periacetabular bone mineral density loss at 3 months follow-up operation.
Keywords: total hip arthroplasty, bone mineral density.
