Y HOC VIET NAM THANG 2 - SO 2/2014
DANH GIA KET QUA BIEU TRI GAY MAM CHAY BANG NEP VIT, VIT XOP TAI BENH VIEN 3 5 4
T O M TAT
48 benh nhan gay kin man chay dUpc phsu thuat ket xUOng ket xu'Ong nep vft va vit xop tai Benh vien 354, tff thang 7/2008 den 12/2012, tuoi tff 17 den 85, 25 BN ton thu'dng do V, VI (52,1%) theo Schatzker.
Ket qua gan 100% lien vet mo ky dau nhUng co 01 BN bien chirng muon hoai tff cO kliu trudc ngoai cang chan do ton thu'dng dong mach chay tru'dc. Ket qua xa danh gia tren 35 BN,' ket qua tdt 60%, kha 28,6%, trung binh 11,4%. Phu'dng phap tuy khong mdi nhUng cd hieu qua, chi phi thap, ky thuat khong qua phffc tap va can ket hdp chat che vdi qua trinh tap van dong sau mo.
S U M M A R Y
EVALUATE RESULTS OF THE TREATMENT OF T I B I A L PLATEAUS FRACTURES BY PLATE AND SCREW AT 3 5 4 HOSPITAL 48 patients with closed fractures of the plateaus, age from 17 to 85, 25 patients were classified type V, VI by Schatzker, were fixed by plate and lag screw from July, 2007 to december, 2012 at 354 hospital.
Early results: The rate of the skin heal on the primary is 100%, but one patient was neerotised muscles of anterolateral aspect of leg due to anterior tibial artery was injured. Long-term results in 35 patients:
excellent: 60%, good: 28,6% and fair: 11,4%.
Although, fixation tibial plateaus fractures by plate and screw is not new method but is effective method, the cost for treatment is low and not complex technique.
Post-operabon, it should be incorporated closely with process of mobilization.
I. OAT VAN OE
Gay mam chay la loai ton thffdng thffdng gap do nguyen nhan chan thffdng. Chiem khoang 1 % cae gay xffdng ndi chung va 8 % gay xffdng d ngffdi Idn. Day la mpt gay xffdng pham khdp, de dan den dfnh, effng khdp goi. Cd nhieu each phan loai gay mam chay, trong do each phan loai theo Schatzker va cpng s y dya tren cac phim ehup Xquang chuan eiia dau tren xffdng chay dffdc sff dung rpng rai tren lam sang. Theo Schatzker, gay mam chay dffdc chia lam 6 loai.
Loai I, I I , I I I la gay mam chay ngoai vdi eac mdc
* Benh vien 354
Phan bign khoa hgc: GS.TS Le Gia Vinh
Ha Phan Th^ng*, Tran Anh Tu3n*
do Iun, di lech khac nhau, loai IV la gay mam chay trong, loai V la gay ea hai mam chay va loai VI la gay hai mam chay vdi dffdng gay tach rcfl dau xffdng khdi than xu'dng [ 4 ] .
* Benh vien 354
Dieu tri gay mam chay noi ehung van la mot khd khan do la gay xffdng pham khdp, de dan den han ehe chffe nang khdp gdi, dang la van de thach thffc ddi vdi cac nha Chan thffdng chinh hinh. Bat cff mot phydng phap dieu trj nao deu phai hydng den 3 muc tieu [ 5 ] :
- Phuc hoi giai phau dien khdp mam chay, ton trpng true cd hpc.
- Cd dinh 6 gay vffng chac tao thuan ldi cho qua trinh lien xffdng.
- Cho phep van dpng va phuc hoi chffe nang sdnfi.
Cd nhieu phffdng phap dieu tri gay mam chay. Lya chon phffdng phap nao phu thupc vao hinh thai 6 gay, tinh trang loang xffdng, phan mem tai cho, benh ly trffdc dd ciia khdp goi, tinh trang toan than (tud'i, benh ly ket hdp) hay kinh nghiem eua phau thuat vien. Ngay nay, vdi si/
phat trien eiia cac phffdng phap ket xffdng, phau thuat da td ra chiem ffu the so vdi dieu tri bao ton, nhat la cac gay mam ehay di lech [4], [5].
Nep vft, vft xdp la mpt phffdng phap 6\l^z ap dung kha lau, rpng rai tren lam sang do ky thuat khong khd, cd dinh manh xffdng kha chac va chi phf khdng cao nhff nep khoa hay cd djnh ngoai.
Tai khoa Chan thffdng Chinh hinli Benh vien 354, thdi gian qua chiing toi da dieu trj phau thuat ket hdp xffdng bang vft xop, nep vit cho 48 benh nhan (BN) gay mam chay. Chimg toi tien hanh danh gia ket qua nham muc tieu:
- Oanh gia ket qua lien xddng 6 gay, phuc hoi chffe nang eua khdp gdi sau mo.
- Rut ra mpt so nhan xet ve chi djnh, Iffa chpn phffdng phap ket xffdng gdp phan nang cao ket qua dieu tri.
II. DOI TU'ONG, PHU'aNG PHAP NGHIEN COV 2 . 1 . D o i tu'dng
48 BN gay mam ehay dffpc dieu tri phau thuat tai khoa CTCH, Benh vien 354. Tff thang 7/2008 den 12/2012.
Y HOC VIET NAM THANG 2 - SO 2/2014 Loai t r d cac BN gay mam chay dieu tri bao
ton, BN dffdc phau thuat nang mam chay Iun do benh ly, cac BN khdng dong y phau thuat.
2.2. Phffdng phap nghien cu'u Nghien cffu hoi cifu mo ta khong ddi chffng.
2.3. Ky t h u a t dieu trj 2.3.1. Tham kham BN:
- Th5m kham BN toan than, tai eho, Iam cac xet nghiem day d u : ehup Xquang, sinh ly, sinh hda.
Oanh gia tinh trang toan than eung nhd tai eho, chii y phat hien va dieu trj cac benh ly ket hdp d ngffdi cao tuoi, tien Iffdng benh.
- Lap ho sd benh an. Danh gia phan loai 6' gay theo phan loai ciia Schatzker lam 6 loai.
- Tien hanh phau thuat. Oang ky, ghi chep phau thuat.
+ Vdi gay mam chay ngoai loai I, IV* chung toi ket xffdng bang vit xdp, neu ft di lech, chung
IlL K i r QUA NGHIEN CU'U
3 . 1 . Oac diem doi tu'dng nghien cffu: 48 BN, cd 25 nam, 23 nff. Tuoi tff 17 den 85, dung binh 44,4 Nguyen nhan: TNGT: 37 (77,1%), TNSH: 7 (14,6%), TNLD 4 (8,3%).
Phan loai ton thffdng theo Schatzker:
toi nan chinh ki'n, bat vft kfn dddi kiem soat eiia man tang sang.
-1- Vdi gay loai I I , I I I , V, VI theo Schatzker, chiing t6i ket xu'dng md, dimg nep L, bat eac vit xop dddi mam chay, cac vit xu'dng cffng d than xddng. Neu ton thu'dng bam tan ciia day chang cheo tru'dc cd dinh bang day thep.
+ Xff trf cae td'n thu'dng ket hdp.
- San soe BN sau mo, chup Xquang kiem tra, hffdng dan tap van dpng.
- Kiem tra dmh ky theo hen.
- Oanh gia ket qua:
-I- Ket qua gan: dien bien toan than, tai cho va ket qua chup Xquang sau mo.
-I- Ket qua xa: chiing tdi danh gia theo tieu chuan ciia Roy Sanders (1991), chia lam 4 mffc dp tdt, kha, trung binh va kem [ 6 ] .
Mu'c do SoBN Ty le %
I 4 8,3
II 7 14,6
III 7 14,6
IV 5 10,4
V 12 25
VI 13 27,1
Cong 48 100
Co 05 BN gay hd, trong do 03 dp I, 02 dp I I theo phan dp ciia Gustilo.Ton thffdng ket hdp: 05 BN kem theo bong viing bam tan ciia day chang cheo trffdc, 01 BN bong vung bam tan ciia day chSng cheo sau, 01 BN gay loi cau ngoai xffdng dui ciing ben, 12 BN gay dau tren xffdng mac eiing ben, 02 BN gay mat ca ngoai eiing ben va 03 BN gay dau dffdi xffdng quay.
Benh ly man tfnh ket hdp: 05 BN tang huyet ap, 05 BN dai thao dffdng typ 2.
3 . 2 . Phffcfng phdp di'eu t r i :
-1- Nan chinh, bat vi't xop kfn: 07 BN (14,6%).
Phau thuat m d : 41 BN (85,4%).
+ Sff dung 1 dffdng mo: 36 BN; 2 dffdng mo: 11 BN. '
+ Dung them vft xop ngoai nep: 14 BN, trong dd 11 BN dffdc diing 1 vi't, 03 BN dffdc ditng 2 vft.
+ Dung chi thep eo djnh cho 06 BN bong diem b^m day chang cheo.
•f Ghep xffdng mao chau cho 02 BN,
Thdi gian tff khi bi thffdng den khi mo:
Vdi 05 BN gay hd: tff 5 den 9 tieng.
- Vdi 43 BN gay kfn: tff 1 den 8 ngay, trung binh 2,3 ngay.
3.3. Ket qua dieu trj:
3.3,1. /(et qua gan:
• 48 BN lien vet mo' ky dau.
- Xquang sau mo: danh gia hinh anh sau mo theo phan dp ban dau nhff sau:
Mu'c do Het di lech Dl lech it Di lech nhieu Cong
I 4 0 0 4
II 6 1 0 7
III 5 2 0 7
IV 4 1 0 5
V 6 5 1 12
VI 7 5 1 13
Cong 32 14 2 48
Nhu' vay CO 32 BN (66,7%) di/dc nan chinh tot, het di lech, 14 BN (29,2%) con di lech it va 2 BN (4,1%) con di lenh nhieu. Cac BN con di lech chij yeu thupc ioai V va V I .Khong co BN nao vit xop di vao 6 khdp.
01 BN bien chuflg hoai tiJ" cO khu tru'dc cSng chan do ton thu'dng dong mach chay tru'dc trong mo.
BN nay phat hien bien chu'ng cuoi thang thiT 2 sau mo.
Y HOC VIET NAM THANG 2 • SO 2/2014
3.3.2. Ket qua xa:
Kiem tra ket qua sau 1 nam dffdc 35 BN.
Tat ea deu lien seo, khdng viem ro. Cd 3 BN seo dinh xffdng.
- Ket qua lien xffdng: 100% benh nhan sau md' lien xffdng chac.
- Co 04 BN di lech thff phat: mam chay Iun hdn so vdi sau md'.
- Cd 13 trffdng hdp teo c6 tff dau diii, 02 BN khdp gdi Idng.
- Khong cd trffdng hdp nao trai vit, gay vit, gay nep Danh gia chffe nang khdp goi theo Roy Co 06 BN bl lech true, qoi md goc ra ngoai <10o
Mii'c do Tot Kha Tr.binh
Kem Conq
I 2 0 0 0 2
I I 3 0 0 0 3
I I I 3 2 1 0 6
Sanders: (n IV
3 2 0 0 5
=35) V 5 3 2 0 10
VI 5 3 1 0 9
Cong 21 10 4 0 35 Ket qua Chung: tdt: 21 BN (60%), kha: 10 BN (28,6%), trung binh: 4BN(11,4%). Khong cd ket qua kem.
Neu tinh rieng Ioai gay V, VI (n = 19), ta cd: tdt 10 BN (53%), kha 6 BN (37,5%) va trung binh 3 BN (19,5%).
IV. BAN LUAN
4.1. Ve dac diem doi tu'dng nghien cu'u Gay mam ehay cd the gap d mpi Iffa tuoi, nhffng chii yeu la tuoi trffdng thanh va ngffdi cao tuoi, chiem 1% trong cac gay xffdng ndi chung nhffng tdi 8% d ngffdi Idn [1]. Trong 16 nghien cffu cua chung toi 100% la gay xffdng d ngffdi trffdng thanh (tff 17 den 85 tuoi).
Nguyen nhan chii yeu do tai nan giao thdng, vdi Iffc chan thffdng trffc tiep cung tydng ty nhy eac nghien ciTu ciia mot so tac gia khac [1], [2], [3]
4.2. Ve lu'a chpn phu'dng tien l<e't xu'dng Chung tdi chi bat cac vi't xop khi gay 1 mam ehay, thanh xydng ddi dien dydc danh gia cdn day, chac lam diem tffa cho vft. Day la phffdng phap ddn gian, de thffc hien, can thiep nhd, ehi phi thap va van dddc ap dung rpng rai cho cac gay mot mam chay.
Chiing toi dat nep d mat trddc ngoai dau tren xffdng chay. Nep vft chiing toi sff dung la nep L. Day la loai nep tffdng ddi mem, de uon de CO the chinh eho op khi't nhat vdi thanh xffdng trong khi mo. Day van la Iffa chpn pho bien hien nay tren lam sang do de kiem, chi phf khong cao.
NhuTig loai nep nay co nhydc diem khong chiu dffdc Iffc ep ma mam ehay phai chju nen thdi gian cho phep b/ nen tren o gay phai sau 6 den 12 tuan. Chimg toi chi dinh cho tat ca cac BN gay ca 2 mam chay va eac BN gay 1 mam chay nhffng danh gia thanh xffdng ben ddi dien khong cdn day, chac. Chiing toi khong dat nep thff hai d phia trong eho BN nao ma chi bat them cac vft ngoai nep do e ngai tinh trang nhiem khuan, com
da tai cho. Mpt sd tac gia [1], [2] chu trffdng dat them nep thff hai khi gay loai V, VI vi cho rang ehi mpt nep la khong du dp vffng chac ngay ca khi sff dung nep khoa. Day la van de chiing toi can quan tam de ap dung trong thdi gian tdi. Vdi 1 nep L va cac vi't rdi co dinh 6 gay la chffa du de CO dinh 6 gay va khong the chiu Iffc sdm, mac diJ cho phep BN tap gap duoi gdi thu dpng ngay tii' 48 gid sau mo. BN 6d<ic phep ty nen mpt phan tff tuan thff 8 (vdi cae BN gay loai I, I I , III va IV) va tff tuan 12 (vdi cac BN gay loai V, VI). Khi kiem tra tren Xquang, 6 gay da co sff lien xffdng kha chae. Do cd sff theo doi, dan do BN ky Iff9ng ve qua trinh tap van dpng sau mo' nen chiing toi chi ghi nhan cd 4 BN bj Iun xffdng sau mo.
Phau thuat md cho 41 BN, trong do c6 11 BN phai md them dffdng mo phfa sau trong de nan chinh dffdc thuan ldi. Chiing toi cung thong nhat nhff nhieu tac gia khac [1][2] khi nhan thay, kh!
gay mam chay cd manii rdi phfa sau trong, rat khd nan chinh va co djnh khi chi sff dung dffdng mo' trffdc ngoai. Neu cd gang nan chinh se gay bam dap phan mem nhieu va tang nguy cd nhiem khuan. Mat khac, d giai doan sau, khdp gdi mat vffng, de gay trffdt ra sau.
4.3. Ve ket qua di'eu trj
Ket qua gan khong ed BN nao nhilm khuan vet mo. Vdi cac BN gay kin, ehiing toi phau thu^t kha sdm (trung binh 2,3 ngay). Mpt so tac gl^
[1,2,3,5] khuyen nen phau thuat muon, nhat I&
ddi vdi cac gay loai V, VI, khi phan mem da het
ne va thong bao ty le nhiem khuan kha cao, c6
the tdi 30%. Trong 16 nghien cffu cua chung toi
Y HQC VIET NAM THANG 2 - SO 2/2014 khong co BN nao nhiem khuan. Cd le do cong tac
vo khuan trong mo dffdc thffc hien tot nhffng do 16 nghien CLTU cd nhieu mffc dp ton thffdng nen chffa du cd sd de danh gia. Cd 01 BN bi hoai tff cd khu trffdc ngoai cang chan, chiing toi se ban luan sau.
Ket qua xa kiem tra dffdc 35 BN deu lien xffdng vffng chac trong d d , ket qua tot: 60%;
kha: 28,6%; trung binh: 11,4%.
Ket qua ciia chung toi tu'dng dffdng vdi ket qua cua Shrestha B.K va cpng sff (2004) danh gia ket qua xa tren 81 BN gay mam ehay dffdc ket xffdng bang vit xop, nep vit. Ti le tdt va kha dat 7 9 % [ 7 ] . Ebraheim Nabil A va cpng sff (2004) danh gia ket qua xa d 114 BN vdi 117 mam chay gay kfn cac loai dffdc ket xffdng ben trong vdi nhieu loai phffdng tien, ket qua chffe n3ng rat tot va tot la 8 1 % , ket qua trung binh la 1 1 % , kem la 9 % [ 1 ] . Mot so cong trinh trong nddc da bao cao, Pham Thanh Xuan (1999) nghien cirtj 41 BN gay kfn mam chay dydc ket xffdng ben trong bang 1 nep, ket qua 85,5% tdt va kha, 14,7% trung binh va kem [ 3 ] . Nam 2004, Nguyen Dinh Trffc nghien cffu 31 BN gay kfn mam chay b i n g phau thuat ket xffdng nep vft, tat ca cac trffdng hdp deu diing 1 nep. Ket qua 88,46%
t o t v a kha, 11,45% trung binh va kem [ 1 ] . Nhuhg ket qua cua eac tac gia khac va eiia chiing tdi cho thay, nep L va vit xop van la mpt lu^
chpn phii hdp de dieu trj gay mam chay, ket hdp vdi qua trinh tap van dpng phuc hoi chffe nang phii hdp se dem lai ket qua dieu trj tot. Tuy nhien cung can ap dung nhuYig phffdng phap gan day dffdc de cao nhff phau thuat 2 dffdng mo, sff dung 2 nep hay khi BN cd dieu kien sff dung nep khda
4 . 4 . Ve b i e n chu'ng p h a u t h u a t 01 BN bj hoai tff khoi ed khu trffdc eang chan do ton thffdng dpng mach chay trffdc trong mo.
Trffdng hq^p nay gay kin mam chay loai VI theo Schatzker, dffdc mo ket xffdng nep vft vdi 1 dffdng mo. Sau mo dien bien on djnh, cat chi lien da ky dau vao ngay thff 14. BN vao vien lai sau 54 ngciy vi te bi phfa trffdc ngoai cang chan va bhn chSn thuong, khong sot, khong dau cang b^n chan, seo mo khong co lo ro. Khi mo lai, cac cd khu trffdc cSng chan hoai tff trSng, vo khuan, da dffi?c cSt hoai tif, dan Iffu, khau da. Sau 3 t h i n g , chung toi phau thuat IBn 3, chuyen gan chay sau ra trffdc, treo gan duoi ngon I. Ket qua BN het ban chan thuong, gdi gap duoi khong han che, dl lai duyc. Trffdng hdp nay chiing toi cho
rang dpng maeh chay trddc da bj ton thu'dng trong mo, cd the do khi dat dung cu nang xffdng va sau do b| tac, gay hoai tff v6 maeh viing ed chi phoi.
V. KET LUAN
Qua 48 BN gay mam chay dffdc ket xu'dng bang vi't xop, nep vft tai Benh vien 354, kiem tra ket qua xa cho 35 BN, chung toi di den mot so ket luan sau;
- 100% BN lien xffdng chac 6 gay. Chffe nang khdp goi: tot: 21 BN ( 6 0 % ) , kha: 10 BN (28,6%), trung binh: 4 BN (11,4%). Khdng cd ket qua kem. Ket qua cho thay, phffdng phap ed hieu qua kha eao trong dieu trj benh ly gay mam chay nhffng can Iffu y ket hdp chat che vdi qua trinh tap van dpng sau mo.
- Phffdng phap khdng khd thyc hien, phydng tien ket xddng khdng dat tien, cd the ap dung de dang d nhieu tuyen benh vien. Odi vdi cac gay ca hai mam chay, cd the md them dffdng mo phfa sau trong de thuan Idi cho nan ehinh va co djnh.
- Can thao tac tinh te trong mo, tranh gay ton thffdng them.
TAI LIEU T H A M KHAO
1. Nguyen Hai An (2013), "Danh gia ket qua dieu tri gay kin mam chay bSng kit hap xddng nep khoa". Luan van cao hoc, Hoc vien Quan y.
I.. Tran Le Dong, Nguyen Tien Binh, Le Phu'dc Cu'dng va My Duy Tien (2012), "Nhan xet budc dau kit qua dieu tn gay kin mam chay loai Schatzker 5-6 bang ket xWdng hai nep vdi hai dudng md", Tap chi Y hgc ThUc hanh (867), so 4/2013, T r . l l - i 4 .
3. Pham Thanh Xuan (1999), "Danh gia ket qua dieu tn gay kin mim chay ngddi Idn tai khoa Chan thddng Chinh hinh Vien quan y 103 va Benh vien Xanh Pon", Luan van cao hoc, Hpc vien Quan y.
4. Chauveaux 6., Souillac V. and Le Huec ].C.
(2002). "Fractures des plateaux tibiaux: fractures recentes". EMC 14-082-A-lO.
5. Le Huec J.C, Chauveaux D., Lesprit D. and Pain F., (2000). "Fractures articulaires recentes de Textremlte supeneure du tibia de I'adulte", EMC 44-805.
6. Roy Sanders (1991), "Double plating of comminuted, unstable fractures of the distal part of the femur", J. Bone and Joint Surg., 73 (A), pp.
341 - 346.
7. Shrestha B.K. (2004), "Tibia plateau fracture:
4 years review at B&B Hospital", Kathmandu Univ.
Med. J., 2(4), pp. 3 1 5 - 3 2 3 .