NGOAI KHOA - SO 2/2011
LL/A CHON GAN GHEP TRONG TAI TAO DAY CHANG CHEO TRl/dC
K H 6 PGOI
Le Manh Son*
Tai tao day ching cheo trirdc (DCCTT) bing manh ghep ca'u tao tijt gan tu do la mot phiu thuat pho bien trong chuydn nghanh cha'n thuong chinh hinh. Muc dich ciia phiu thuat la phuc hoi su vung chic chong su di lech ra trirdc cua khop goi. Khi quyft dinh phiu thuat thi phiu thuat vien phai xac dinh nguygn lieu lam manh ghep thay the DCCTT tot nhat de dat dugc muc dich. M6t gan ghep ly tucmg cho tai tao day chang cheo trudc can CO do chac khoe it nha't la tuong duong vdi DCCT binh thudng, cd dac diem co sinh hoc nhu DCCT nguydn ban, cho phep c6' dinh chac va khoe, nhanh chdng hop nha't sinh hoc vdi CO the va giam thieu td'i da thuong ton tai viing cho gan. Hi6n nay cd rat nhieu lua chon gan ghep bao gom gan tu than, gan dong loai va tdng hop.
Gan tdng hop cd im didm: khoe, khong bi tdn thuong tai chd cho gan va cung ca'p khdng han che. Tuy nhien su khdng dung nap cCia CO the, hien tuong tran dich khdp trudng dien, nhiem triing muon, gia dit va ti le phiu thuat lai (revision) cao da lam cho gan ghep tdng hgp khdng dugc sijf dung rdng rai.
Gan ghep tu than bao gom: Gan banh che, gan khoeo chap bdn, va gan tii diu dui cd hoac khdng cd xuomg.
Gan ghep ddng loai sin cd vdi gan gdt, gan banh che. gan chay tnrdc, gan chay sau, gan khoeo.
Muc tieu ciia bai nay nhim cung cap cac thdng tin nghien cuu ve cac ngudn gan ghep phd bien dung de tai tao DCCT, giiip cho phiu thuat vien lua chon manh ghep phii hgp nhat theo kinh nghiem ciia minh va yeu ciu ciia ngudi benh.
1. GAN GHEP TU THAN:
l.l. Gdn bdnh che:
Nam 1963 Jones [1] md ta dung 1/3 giO'a gan banh che vdi hai dSu cd xuong cho tai tao DCCT. Sau dd trd thanh tieu chuin vang cho viec tai tao DCCT. Gan banh che da dugc dimg rdng rai de tai tao DCCT do dac diem sinh ly hgc khde va chic ciia nd, manh ghep bing gan banh che 9-10mm cd do chic khoe bing 120% DCCT binh thudng [2,3]. Hon niia do cd hai mit xuong hai diu nen kha nang lien xuong vdi xuong trong dudng him tdt, va kha nang cd dinh viing chic manh ghep cho phep ap dung cac chuong trinh phuc hdi chiic nang tich cue sau md.Trung binh su lien gan vdi xuong trong dudng him cd the tdi 12 tuin, trong khi dd su lien xuong vdi xuong chi ma't 6 de'n 8 tuin. Nhieu nghien ciiu da cho tha'y ke't qua rat tdt vd do viing ciia gdi, ngudi benh cd the trd lai miic do hoat ddng the thao trudc khi bi chan thuong, va su hai long ciia ngudi benh. [4]
Hiu het la'y gan cung ben, tuy nhien cd mdt sd tac gia la'y gan banh che ben kia vdi ' B?nh vi?n Vi?t Due
muc dich phuc hdi chiic nang rieng re va gdi it bi anh hudng do phiu thuat nSn se dugc phuc hdi nhanh han, tuy vay no lai tao ra tdn thuofng tai chd la'y gan cho gd'i lanh.
Tuy nhien v^^n dd cin can nhac khi tai tao DCCT bang gan banh che la thuong tdn tai chd cho gan. Dau d khdp diii banh che mac du da dugc cai thien rat nhieu nhd vao cac ky thuat phuc hdi chiic nang mdi nhung vin cdn la va'n de quan tam. Miic do dau tii thinh thoang tdi anh hudng cac hoat ddng hang ngay va thd thao.Ti le dau khdp diii - banh che sau tai tao DCCT bang gan banh che tii 3-50% [4]. Tuy nhien ti le dau d diii- banh che sau tai tao DCCT bang gan khoeo tdi 20%[6] va 22% tren nhiing benh nhan eg tdn thuong DCCT nhung khdng phiu thuat tai tao [7]. Nhidu nghien cuu cd ging lam sang td nguyen nhan gay dau khdp diii banh che sau phiu thuat tai tao DCCT. Cac nguyen nhan cd the gay ra dau bao gdm : tdn thuong thoai hda sun san cd trudc khi phiu thuat, tdn thucmg do phiu thuat, dat manh ghep khdng diing vi tri, tdn thuong xo hda lam co g^p gdi va ket xuong banh che. Banh che cao, thip sau phiu thuat DCCT d i dugc md ta nhung khdng lien quan rd rang. Burs va cdng su thiy rang chu vi vdng diii giam cung vdi 84%
dau khdp banh che dui. Sachs md ta su lien quan giiia dau mat trudc gdi, co tii diu diii yeu va su co riit ga'p gdi sau phiu thuat[8].
Sherboume[5] tin tudng rang dudi gdi het miic ngay sau phiu thuat giiip loai bd dau mat trudc gdi do khi dudi gdi lam manh ghep nim trong horn lien Idi ciu tranh su hinh thanh td chute seo. Nhiing ngudi cd tdn thuong sun do 3, 4 d banh che se dau mat trudc gdi sau khi md tai tao DCCT nhidu hon.
Ydu CO tii diu diii sau tai tao DCCT bang gan banh ihe cung la v ^ dd quan tam.
Rosenberg [9] da danh gia churc nang dudi gdi tren 10 benh nhan dugc lua chgn nglii nhien, theo doi 12 ddn 24 thing sau tai tao DCCT bang gan banh che. Kdt qua la 8/10 benh nhan cd dau khdp diii - binh che khi ngdi lau hoac leo cSu thang .Nam benh nhan cd thay ddi khdp dui- banh che tren x- quang sau md so vdi trudc khi md. Ti le gan tii diu- tii diu so vdi chan lanh giam tren test isokinetic. Miic dd giam nhidu nhit la 6 607giay vdi miic thidu hut trung binh la 18%.
Tren chup cat ldp vi tinh tha'y teo ca tii diu diii ma rd ret nhit la co rdng trong.
Xo hda khdp da ttaig la vin dd nhiic nhdi, ngay nay da giam ro ret nhd su phat tridn cac chuong trinh phuc hdi chiic nang tich cuc[5].
Viem gah banh che cung gay khd khan trong qua trinh phuc hdi chute nang nhung chi gap khoang 10% sd benh nhan trong khoang thdi gian 3-6 thing diu va thudng tu het sau khoang 1 nam.
Dau khi quy gdi la di chiing dac thu khi tai tao DCCT bing gan banh che (31-44%) va thudng khdng het han theo thdi gian. Ngudi benh cin dugc thdng bao trudc vd di chiing nay.
Theo mdt nghien cihi sau 5 nam theo doi trinh bay tai hdi nghi thudng nien AAOS nam 2002 quan ngai vd xu hudng bidn ddi thoai hda khdp tren nhdm benh nhan diing gan banh che tai tao DCCT (18%) cao hon so vdi nhdm benh nhan diing gan khoeo (4%). Tuy nhien. Bach va cdng su sau 5-9 nam theo ddi thiy rang su thoai hda khdp la khdng dang ke. Mdt sd bao cao lai cho tha'y sU lien quan
NGOAI KHOA - SO 2/2011
gifla thoai hda khdp vdi tinh trang cua sun chem tai thdi didm phiu thuat.
Te bi phia ngoai dudng rach do cit nhanh dudi banh che cua thin kinh hien va seo dau la phd bien sau liy gan banh che.
Tuy nhien cic trieu chiing deu cai thien va theo thdi gian khdng cay thieu hut chute nang.
Mdt sd bidn chiing nhu diit gan banh che ,gay xuong banh che ra^ hiem gap va cd the tranh dugc khi tidn hanh phiu thuat tuan thii theo dUng quy trinh ky thuat.
1.2. Gdn khoeo
Gan khoeo cung de tai tao DCCT ngay cang phd bidn do it gay thuong tdn tai chd la'y gan, manh ghep khde, them vao dd su tidn bd cua phuemg tien cd dinh cho phep cd dinh viing chic. Sgi dan cua gan ban gan va gan CO thon cd do khde 1216N va 838N, manh ghep bing gan khoeo gip bdn cd luc cang td'i da 4108N gin gip 3 lin DCCT binh thudng, dd chic ciia gan bing 807N xip xi gip 3 lin DCCT binh thudng, gip 2 lin manh ghep gan banh che 10mm. Theo kdt qua nghien cuu ciia Noyes va cdng su thi manh ghep gan ban gan chap ddi cd do khde bing 140% DCCT binh thudng va manh ghep chap bdn bing 250% dd khde ciia DCCT [3]. Hamner va cdng su cung chiing td ring chap ddi gan ban gan se cd manh ghep cd luc cang manh ga'p ddi gan ban gan ban diu. Hinh tru cua gan khoeo cd thidt dien cit ngang Idn hon gan banh che (55mm^ so vdi 33,2mm^) trong khi DCCT binh thudng xa'p xi 44,4mm^ Han niia vdi hinh dng dd manh ghep se viia khit vdi hinh dng ciia dudng him xuong do vay tranh dugc su rdng ra ciia dudng him.
Wo va Adams nha'n manh tim quan trgng ciia dd ciing chic tuydn tinh ben canh
luc tai td'i da trong viec lua chgn manh ghep.
Do Cling chic qui cao cd the anh hudng tdi ddng hgc ciia gdi, gay ra luc ep Idn tren phuemg tien cd dinh hoac gay tdn thuong vi the cho manh ghep. Noyes da chiing td dd chic ciia manh ghep bing gan khoeo tuong duong vdi DCCT, trong khi dd manh ghep bang gan banh che gap 3,76 lin do ciing ciia DCCT [3]. Nhu vay manh ghep bing gan khoeo 4 sgi lam bing gan ban gan va gan co thon gap ddi, khde hon manh ghep bing gan banh che va cd do cung tuyen tinh gidng vdi DCCT.
Ly do chinh diing gan khoeo thay the gan banh che vi it thuong tdn tai chd va khdng tdn thuang he thdng dudi gdi. Gan khoeo dugc chi dinh dung thay the gan banh che trong mdt sd trudng hgp ma gan banh che khdng diing dugc nhu: benh nhan xuong chua trudng thanh (lien quan den sun phat trien), benh nhan cd gan banh che nhd (thudng la phu nii), benh nhan bi benh khdp diii banh che, tang cudng cho DCCTT bi tdn thuang khdng hoan toan...Ben canh dd nhihig van ddng vien hoat ddng chinh d he thdng dudi gdi nhu: dua xe dap, miia ba-le, trugt tuydt, nhay cao, nhay xa, thudng khdng hai long vdi manh ghep lam tdn thuong he thdng dudi gdi nhu gan banh che.
Marder va cdng su so sanh ket qua tai tao DCCT bing gan binh che tu than vdi gan ban gan va gan ca thon chap ddi. Ket qua cho tha'y cd su ydu rd ret luc td'i da ciia gan khoeo d dO'Vgiay ddi vdi nhdm diing gan ban gan va gan CO thon. Khdng cd su khac biet dang kd giiia hai nhdm vd co luc co tii dau.
Vdi muc tieu lam rd tdn thuong khi la'y gan khoeo, Yasuda va cdng su so sanh su tdn thuang sau liy gan ban gan va gan co thon
NGOAI KHOA-so 2/2011 khdng tai tao DCCT vdi la'y gan khoeo cd tai
tao DCCT. 34 benh nhan dugc la'y gan khoeo dd tai tao DCCT bdn ddi dien va 31 benh nhan lay gan khoeo dd tai tao DCCT ciing ben. Gdi khdng phiu thuat trong nhdm la'y gan ciing ben lam nhdm chiing. Ca luc dang trudng ciia gan khoeo nhdm la'y gan tai tao DCCTT ben ddi dien ydu hon rd ret so vdi nhdm chiing sau md 1,3,6 va 9 thing. Nhung sau 12 thing khdng cdn su khac biet cd y nghia thdng ke. So vdi nhdm liy gan khdng thi nhdm liy gan tai tao DCCT ciing ben ydu hon dang ke tai thdi diem sau md 1 thing, tuy nhien sau 12 thing thi khdng cd su khac biet giiia hai nhdm. Hon niia khdng cd su khac nhau vd chiic nang co tii diu giiia hai nhdm. Rit hidm khi phai han chd ddng tic vi ly do gay dau tai viing cho gan. Tic gia kdt luan gan ban gan va gan co thon la su lua chgn hgp ly dd tii tao DCCT, giam thidu tdn thuang tai chd cho gan
Su ydu didm ciia gan khoeo la su lidn gan va xuong trong dudng him. Su viing chic ngay khi cd dinh cua gan vao xuong ydu hon la xuong vao xuong. Rodeo dinh gia su lidn gan - xuong tren chd dudi luc vat ly. Ong diing gan dudi dai ngdn chan dat qua Id khoan vao viing hanh xuong chay, sau dd cut mdi 2 tuin thi gan se bi keo ra dd danh gia vd su lidn gan xuong. Kdt qua la: sau 2-4-8 tuin gan bi keo bat ra hoan toan, d khoang 12 ddn 26 tuin gan se bi dut d chd kep hoac d lung chiing. Kdt qua nay lien quan ddn su mgc xuong va lidn td chiic trong dudng him.
Tic gia khuyen cao bao ve qua trinh lidn gan- xuong it nha't 8 tuin
Ngoai ra cd mdt sd nghien ciiu tha'y ring dung gan ban gan va co thon tii tao DCCT cd the gay han chd dd khde cua ddng tic ga'p gdi
va dudi hang do vay se anh hudng tdi nhiing van ddng vien ddi hdi cao vd do khde khi gip gdi tren 90" nhu chay nude riit, the dung dung cu, ju-dd, vat.
1.3. Gdn tii ddu
Sii dung gan tur diu di tii tao DCCT lan diu tien dugc Marshall md ta nam 1979 sau dd dugc phd bidn bdi Blauth vao nam 1984 va Furkerson nam 1995. Lfu diem manh ghep bang gan tii diu la dudng rach da d tren xuong binh che tranh tdn thuong nhinh dudi banh che cua thin kinh hidn va dudng nhu it dd lai tdn thuong tai chd liy gan so vdi liy gan binh che. Gan tii diu dui dugc liy vdi 1 diu cd xuong binh che giiip qua trinh lien xuong - xuong d mgt diu dudng him. Staubli nghien ciiu dac diem ca'u tnic va co hgc ciia gan tur diu- banh che, so sanh vdi gan binh che tha'y ring: thidt dien cit ngang gan tii diu la 64.4mm^ Idn hon gan banh che la 36.8mm^, nhung gia tri luc cang ciia gan banh che Idn hon rd ret so vdi gan tii diu (53.4N/mm^ va 33.5N/mm') Griffith va cdng sur khdng tha'y su khic biet giiia gan banh che va gan tii diu sau 1 nam. Fulkerson khdng tha'y bien chiing ding kd vdi tren 60 ca theo ddi tren 2 nam.
2. CAN OONG LOAI
Sli dung gan ddng loai dd tai tao DCCT da dugc tren 20 nam phat trien va ngay cang trd nen phd bien
LTU didm: Do khdng mit thdi gian la'y gan nen giam dugc thdi gian phiu thuat.
Khdng bi tdn thuong tai chd cho gan, va do khdng phai la'y gan nen dudng md nhd hem, cd thd tai tao ca hai ben hoac nhidu day ching. Them niia ludn sao cd cac loai gan tu
NGOAI KHOA - SO 2/2011
than vdi cac kich cd khac nhau, cd xuong hay khdng cd xuong tiiy theo sd trudng phiu thuat vien. Cic gan ddng loai chu yeu la :gan binh che, gan gdt, gan khoeo, gan chay trudc, gan chay sau.
Ngugc lai viec diing gan tir than cd nhiing nhugc diem: nguy co truyen benh, phan utig midn dich, anh hudng ciia qui trinh bao quan va khi trung tdi chit lugng gan, cham tai tao va ddng hda vdi co the, seo hda va tang gia cua phiu thuat khi dimg cho nhiing ngudi tdn thuang DCCT lin dau.
Dung gan ddng loai tai tao DCCT cd nguy CO truyen benh do vi rut nhu HIV. viem gan B, viem gan C. Cd 2 each khii trung:
dung d-xit ethylene va tia xa. Do d-xit ethylen cd thd gay viem mang hoat dich, hdng manh ghep va tao cac nang quanh dudng him nen ngay nay it dung. Khii triing bing tia gamma an toan va hieu qua. Ngay nay vdi kl thuat enzim phat hien virus mdi se giam nguy co truydn benh Vien nang lugng nguyen tii qudc te chap nhan lieu chuan la 2.5 Mrad cho td chiic sinh hgc, hau het cac ngan hang md dung lidu tir 1.5 den 2.5Mrad.
Vdi lidu 2.0 den 2.5 Mrad vius HIV vin dugc tim tha'y bdi phan ling chudi polimesome. Chi vdi lieu 3.0 Mrad hoac Idn hon thi mdi khdng tha'y su cd mat ciia virus. Tuy nhien do khde ciia gan giam di rd ret vdi lidu Idn hon 2.5 Mrad. Noyes khuyen cao diing lieu 4.0 Mrad.
Ngudi ta dir doan nguy co bj truyen HIV khi dimg td chiic ddng loai la 1/1700000.
Nhidm trung la mgt bidn chiing hiem gap sau tai tao DCCTT. Mdt bao cao ve trudng hgp nhidm trung sau md gay tii vong vdi vi khuin ky khi Clostridium sordellii xay ra vdi benh nhan ghep sun khdp gdi ddng loai nam 2001. Trung tam phdng chdng benh Hoa Ky
khuydn cao nen sii dung phuang phap tiet trung diet dugc nha bao, neu khdng phiu thuat vien phai ludn y thirc ve nguy co nhidm khuin.
Can bing lugng gamma dd khii triing dugc virus ma khdng thay ddi dac tinh co hgc ciia td chiic la khd khan .Salehpour va cdng sir da nghien ciiu tac dung ciia lidu 4-8 Mrad cua tia gamma tren gan banh che de. Su giam lire td'i da va do chic do lidu phdng xa dugc quan sat. Nghien curu thii 2 ciia Salehpour so sanh gan banh che ciia ngudi cd hoac khdng dung tia xa vdi lidu 4 Mrad. Kdt qua nhdm diing 4 Mrad giam ro ret do chic, luc tdi da va do co dan .
Mot nhugc diem nira ciia gan ddng loai la cham ddng hda sinh hgc vdi co the. Mot sd bao cao ghi nhan sir khdng lien ciia mit xuong trong dudng ham. Gan tu than va gan ddng loai deu trai qua cac qua trinh ddng hda bao gdm: hoai tii manh ghep, tai sinh td bao, tai tao mach va tai tao sgi keo. Jackson va ddng nghiep so sanh md benh hgc va tinh trang vi mach ciia gan banh che tu than va ddng loai tren de. Sau 6 tuan gan ddng loai the hien .su tang sinh mach va tang qua trinh viem. Sau 6 thang gan ddng loai the hien qua trinh hinh thanh cham chap cac sgi collagen dudng kinh Idn. Trong khi dd gan tu than cd cac sgi collagen cd thiet dien cat ngang Idn hon chi vdi 6 tuan. Shino nhan thay cac sgi collagen trong tai tao DCCT bang gan ddng loai hau het la cac sgi dudng kinh nhd va khdng gidng nhu day ching binh thudng mac du sau phiu thuat nhieu nam.
Noyes bao cao theo ddi 7 nam vdi ket qua 78% ciia gan cang diii va 82% ciia gan banh che ddng loai da phuc hdi dugc do viing ciia gdi sau khi tai tao DCCT cap tinh. Ti le
NGOAI KHOA - SO 2/2011 that bai nhin chung la 14%. Vdi tdn thuang
DCCT man tfnh ti le that bai la 17%. Noyes khuyen cao dung gan dong loai cho phiu thuat tai tao lai DCCT hoac trong nhu'ng trudng hgp dac biet khi ma gan tu than khdng cd sin.
Sabrina khuyen cao dimg gan ddng loai tai tao DCCT cho nhu'ng ngudi tren 45 tudi va nhu'ng ngudi ma yeu cau cdng viec hoac mdn thd thao ddi hoi phai quy gdi.
3. KET^iyAN:
Mm^mot loai gan deu cd nhu'ng uu didm va nlurgc diem rieng. Lu'a chon manh ghep phii hgp dd tai tao DCCT phu thuoc \'ao nhidu yeu td nhu quan niem va kinh nghiem cua phiu thuat vien, cac ngudn gan sin cd tai thdi diem phiu thuat (vi du nhu: cac tdn thuong gan trudc klii phiu thuat. benh nhan ph3u thuat lai, ...), miic do hoat dong \'a yeu cau ciia ngudi benh.
TAI UEU THAM KHAO:
1. Jones KG. Reconstruction of the anterior cruciate ligament: a technique using the
central one- third of the patella ligament.
J Bone Joint Surg 1963;45:925-932.
2. Cooper D, Deng X, Burnstein A, et al.
The strength of the central third patellar tendon graft. Am I Sports Med 1993; 21:
41-7
3. Noyes FR, Butler DL, Grood ES, et al.
Biomechanical analysis of Human ligament graft used in knee-ligament repairs and reconstruction. I Bone Jiont Surg Am 1984;66:344-52.
4. NeddefT DD, Bach BR J. Arthroscopic anterior cruciate>ligament reconstruction using patellar tendon autograft.
Orthopaedics 2002;25:343-57.
5. Shelbourne KD, Wilckens JH, Mollabashy A, et al. Arthrofibrosis in acute anterior cruciate ligament reconstruction: effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991;19:332-60.
6. Shaicb MD, Kan DM, Chang SK, et al.
A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction. Am I Sports Med 2002;30:214-20.
