Y HOC VIET NAM THANG 10 - SO 2/2010
DANH GIA KET QUA BlTflfC DAU THAY LAI KHQTP HANG TAI BENH VIEN TRUNG ITONG QUAN DOI T 08
•^i • Luu Hong Hai, Nguyen Tien Binh, Le Hong Hai, Nguyen Quoc Diing Phiing Van Tuan, Mai D5c Viet, Le Hanh(*)
TOMTAT ,j .
21 khdp hang dffpc phau thuat thay lai toan phan tai Vien Chan thffdng Chinh hinh, Benh vien Trung ffpng Quan dpi 108 tff nam 2002 den 2010. Thdi gian theo ddi trung binh 3,2 nam (1 thang den 8 nam). Trong dd cd 13 khdp hang phai thay lai toan bd, 5 khdp chi thay stem, 3 khdp chi thay d cdi. Cd 10 trffdng hpp phai ghep xffdng tff than va dong loai.
21 khdp dffdc danh gia theo tieu chuan cua Paul M. Pellicci va cpng sff, cd 20 khdp thay lai dat ket qua rat tdt va tdt, 1 khdp that bai do bien chffng nhilm triing sau, viem rd khdp.
Chung tdi thay rang ket qua ban dau phau thuat thay lai khdp hang rat kha quan. Tuy nhien, can theo ddi, danh gia ket qua dieu trj cho nhieu benh nhan hdn, trong thdi gian dai hdn.
ABSTRACT g 21 revised total hip replacements that were performed at the Traumatology and Orthopaedics Institute, 108 Central Military Hospital from 2002 to 2010. The mean follow-up time was 3,2 years (range: 1 months - 8 years). 13 hips were revised all components, 5 were revised isolated femoral stem and 3 were revised isolated acetabular component. We had bone grafts for 10 hips. The preliminary results were evaluated according to the rating system for revision total hip replacements of Paul M. Pellicci and al.
Result: 20 (95,24%) of these hips were rated as excellent or good, 1(4,67%) was rated as poor (deep infection)
Conclusion: the preliminary results were perspective. However, it needs to follow-up and assess for more patients in a more longer time.
Key word: revised total hip replacements, revision total hip arthroplasty
I. OATVANOE
Hien nay, tren The gidi ndi chung va d Viet Nam ndi rieng, sd lupng benh nhan dupc phau thuat thay khdp hang ting len hing nam. Nhd ky thuat nay ma chffc nang khdp hang cffa benh nhan dupc phuc hdi, chit lupng cuoc sdng dupc cai thien rd ret.
Tuy nhien, dff cd nhieu tien bd trong nghien cuu ve CO sinh bpc cffa khdp nhin tao, vd ky thuat md vl ve chit lieu thay thd khdp, nhung ngay cing nhieu benh nhin thay khdp hing van phai ddi mat vdi nhiing bidn chung sau md nhu nhiem khuan, Idng/sai khdp, long d cdi, long chudi... day cung 11 cac chi dinh hang dau cua thay lai khdp hing.
Cffng vdi su gia ting sd lupng benh nhan dupc phau thult thay khdp hing, so benh nhin thay lai khdp cung ting len hing nlm.
Tai My, sd benh nhan thay lai khdp chidm khoing 17%-37% trong tong sd khoang 300.000 benh nhan thay khdp hang hang
(V B?nh vi?n TW Quan doi 108
-> JJis:'
HOI CHAN THUONG CHINH HINH VIET NAM - HOI NGHI KHOA HOC TOAN QUOC LAN THLf IX
nlm, ket qua cd tdi tren 90% benh nhan dat tdt vl rit tdt [4]
Tai Viet Nam, thay khdp hang mdi bit diu tien hlnb tff nhiing nam 1990. Hien nay, hing nlm cd hing nghin benh nhan dupc phlu thult thay khdp, trong dd cd hang tram benh nhin thay lai khdp hang. Ky thuat thay lai khdp hing la ky thuat khd, ddi hdi phlu thuat vien phai cd trinh dp chuyen mdn sau, cic CO sd y te phii cd trang thiet bi vl vat lieu thay the khdp phff hpp. Vi vly, chi cd 1 sd Benh vien ldn mdi thuc hien dupc ky thult nay. Tai Benh vien Trung uong Quan dpi 108, thay lai khdp hing da tien hinh tff gan 10 nam nay. Tuy nhien chua cd bio elo chinh thffc nio ve ket qua dieu tri cffa ky thult nly. Vi vay chung tdi nghien cffu de tai
"Ddnh gid kit qud bir&c Mu thay lai kh&p hdng tai Binh viin Trung irang Qudn dpi 108" nhim muc dich : Rfft ra mdt sd nhan xet ban dau ve ket qua dieu tri, ve phin loai vl chi dinh phlu thuat cffa phau thuat thay lai khdp hing.
II. Odi TUONG VA PHUONG PHAP NGHIEN CCfU
21 benh nhan (21 khdp hing), trong dd cd 12 nam va 9 nff dupc phlu thuat thay lai khdp hang toln phin. Thdi gian theo ddi trung binh 3,2 nam (1 thing den 8 nam), dp tudi trung binh 56,4 (tff 38-77 tudi).
Khi vao vien, elc benh nhan dupc tham khlm lam sang: hdi benh phat hien cic trieu chffng chu quan nhu dau, ban che van ddng, sung ndng khdp, kham benh phlt hien cac trieu chffng ldng khdp, ban che van ddng, nhi|m trffng khdp.
Tham khlm can lam sang gdm chup Xquang thudng qui khdp hang hai ben tu the thing, chup Xquang khdp hing ben benh tu the nghieng, can thiet cd the chup chech
chau, chdch bit hoac CT Scanner kdt hpp, ngoli ra khi nghi ngd cd tinh trang nhiem khuan cin lam cac xet nghiem chan doln nhu cdng thffc mlu, mlu ling, CRP (protein phan lingC).
Sau khi khlm llm sing va can lam sing, tdn thuong dupc phin loai theo ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) cua Trung tam Cham sdc va Dich vu Y te va Trung Tam Thdng ke Benh tat Qudc gia My [4] , theo cac bien chffng sau thay khdp ky diu nhu Idng/sai khdp, vd/gay cic bd phan khdp nhan tao, gay xuong, mdn d cdi, nhiem khuan, cac bien chffng khic.
Tat ca benh nhan dupc phau thuat thay lai khdp hang toln phan. Phuong phlp md cd the thay toan bp cic thanh phan cffa khdp nhan tao, hole chi thay d cdi hole stem. Tien hanh ghep xuong d cdi va xuong dffi theo chi dinh.
Sau md benh nhan dupc hudng din tap van ddng theo chuong trinh cffa Vien Han lam cic Phau thuat vien Chinh hinh My (American Acedemy of Orthopeadic Surgeons), khuyen khich van dpng sdm, tang sue manh cffa cic co vung dui va hdng, dac biet luu y cac tu the phdng sai khdp nhan tao nhu gap hing, xoay ngoli khdp hang qua mffc.
Ket qua theo ddi dupc danh gil tren cac mat: tai bien trong md nhu gay xuong, tac huyet mo..., elc bien chffng sau md nhu nhiem khuan ndng, sau, sai khdp, liet than kinh hdng to, sai khdp, ldng cic thanh phan cua khdp...
Ket qua chung dupc danh gia theo tieu chuan cffa Paul M. Pellicci va cdng su [5], dua tren cac tieu chuin dau, kha nang di lai, chffc nlng boat ddng vl bien dp van ddng khdp, X quang 6 cdi vl xuong dui, chia lam 4 mffc dp: Rit tdt dat 51-60 didm, tdt dat 41-50 diem, kha dat 31- 40 didm, xiu < 30 diem.
Y HOC VlgT NAM THANG 10 - SO 2/2010
III. KET QUA VA BAN LUAN
Phan loai ton thuong trudge mo
Bdng 1: Phan loai chin doln trudc md theo ICD-9-CM (n=21)
STT 1 2 3 4 5 6 7
Phan loai ton thUtfng Ldng cac bd phan khdp nhan tao
Mat vffnq/sai khdp
Vd, gay cac bp phan khdp nhan tao Gay xffdng
Nhiem khuan khdp nhan tao Mdn d cdi
Bien chffng khac cua khdp nhan tao
So lu'dng khdfp 12
2 0 2 2 3 0
Tvie 51,14%
9,52%
0%
9,52%
9,52%
14,29%
0%
Quan sit bing 1 chffng tdi thiy, phan ldn benh nhan bi ldng khdp nhan tao, trong 12 trudng hpp ldng khdp nhan tao, cd 5 trudng hpp chi ldng stem, 3 trudng hpp ldng d cdi, 4 trudng hpp ldng ca d cdi va stem. 2 benh nhan sai khdp ra sau len tren (the chau), trong dd 1 trudng hpp do benh nhan bi nga llm cho khdp hang gap qui mffc, 1 trudng hpp do dat d cdi qua dffng va ra trudc. 2 trudng hpp gay xuong, trong dd I trudng hpp vd diu tren xuong dui, 1 trudng hpp gay 1/3G xuong dui sat vdi stem, ca hai benh nhan nay deu ldng d cdi ket hpp. 2 trudng hpp nhiem trffng khdp deu den vien trong
giai doan mudn, khi da viem rd mu. 3 benh nhin mdn d cdi sau thay chdm Moore.
CIc nghien cffn tren the gidi ve thay lai khdp hing cffa cac tac gia nhu Pellicci va cdng su (1985) [5], Andrew L. Whaley va cpng su [2] (2001)... deu thay rang nguyen nhan chu yeu din den thay lai khdp deu do ldng khdp, mat vffng/sai khdp vl nhiem khuan. Nam 2005, theo thong ke cffa Trung tam Cham sdc va Dich vu Y te va Trung Tam Thdng ke Benh tat Qudc gia My, trong tdng sd 51.300 khdp hing thay lai, nguyen nhan chff yeu do ldng, mit viing/sai khdp nhin tao (42,2%) va nhiem khuin (14,8%).
Phan loai phau thuat
Bang phan loai phau thuat theo ICD-9-CM (n=21)
STT 1 2 3 4 5 6 7
Phu'dng phap phau thuat Thay lai toan bd
Thay 6 cdi Thay stem Chi thay chdm/ liner Cat doan khdp/ thao bd dung cu Kiem tra khdp, khdng thay the cac bp phan.
Cac phau thuat kep hdp
So benh nhan 13
3 5 0 0 0 0
Tyle 61,90%
14,29%
23,81%
0%
0%
0%
0%
HOI CHAN THUONG CHINH HJNH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN THlf IX
Trong 13 benh nhin thay lai toan bd, cd 4 benh nhin ldng ca d cdi nhan tao vl stem, 3 trudng hpp mdn diy d cdi sau thay chdm Moore, 2 trudng hpp nhiem khuan khdp nhan tao, 2 benh nhin sai khdp sau thay khdp hing toln phan, 2 trudng hpp sau thay khdp ky dau bien chffng gay xuong dffi. 5 khdp chi ldng stem, d cdi vung, dat dffng vi tri nen chi thay stem. 3 khdp thi ldng d cdi, stem virng, nen chi thay d cdi. Trong 21 khdp dupc thay lai chffng tdi tien hlnb ghep xuong cho 10 trudng hpp, trong dd 4 trudng hpp ghep xuong ddng loai.
Ve chi dinh thay lai d cdi, Allan vl cpng su [1] chia tdn thuong d cdi thinh 5 type, type I: khdng thiy diu hieu khuyet xuong, type II: cd diu hieu khuyet xuong, cup kim loai tiep xffc vdi d cdi, type III: khuyet xuong nhd hon 50% d cdi, type IV: khuyet xuong tren 50% d cdi, type V: llm mat tinh lien tuc cua khung chau (thffng d cdi). Tuy theo loai tdn thuong d cdi cd chi dinh dieu tri khic nhau, cd the don thuin chi can thay cup ldn hon, hole cup cd xi mang. Vdi nhiing khuydt xuong ldn (type III, IV, V), cin phai tao hinh d cdi bing ghep xuong, ket hpp thiet ke nhung khdp chuyen biet.
Thuc te, trong dieu kien trang thiet bi vl vat lieu khdp nhin tao chuyen biet cdn thieu, vdi nhiing trudng hpp khuyet xuong ldn chffng tdi tien hlnb ghep xuong ddng loai.
Cdn vdi nhung trudng hpp khdng khuySt xuong hole khuyet xuong it chffng tdi chi cin thay the bing cup vdi cd ldn hon, hole cup cd xi mang.
Ve thay lai stem xuong dffi, trong 18 trudng hpp dupc thay stem (13 trudng hpp thay lai toln phin va 5 trudng hpp chi thay stem), theo phan loai cua Harris va cpng sir
[3] cho stem cd xi mlng va Engh vl cdng sir [6] cho khdp khdng xi mlng, tat ca cac benh nhan deu ldng stem rd ring, tham chi gly thffng thinh xuong hole gay xuong. 18 trudng hpp tren, chat lupng xuong dffi cdn tdt nen chffng tdi chff truong thay stem khdng xi mlng, vdi nhiing trudng hpp cd gay xuong dffi kem theo, chffng tdi chu truong ghep xuong tu than hole ddng loai.
Ve ket qua dieu trj - i i Vdi 21 khdp dupc thay lai. Theo phan lai cffa Paul M. Pellicci vl cdng sir, cd 20 benh nhan dat ket qua rat tdt va tdt, trong do cd 9 benh nhin dat ket qua rat tdt (dat 51-60 diem), 11 benh nhin khic dat ket qui tot (dat 41-50 diem), cac benh nhin nay deu trd lai cic boat ddng thdng thudng, khdng phu thudc vio cac phucmg tien hd trp (khung, nang...) khi van dpng, ket qui danh gil tren Xquang khdng thay cd bien chffng ldng, gay elc bp phan khdp gia, khdng bi sai khdp. 1 benh nhan ket qui xau do nhilm khuin, viem dd keo dai, phii thao bd toan bp khdp nhan tao.
Trong qui trinh thay khdp khdng cd benh nhan nao gap cac tai bien nhu gay xuong, tie huyet phdi. Khdng cd bidn chffng sai khdp, liet than kinh hdng to, ldng, gay cac bp phan khdp nhin tao. 1 trudng hpp biln chffng nhiem khuan slu, vdi trudng hop nay, trudc dd benh nhan nay da nhiem khuan sau thay khdp ky diu, sau khi dupc thio bd khdp nhin tao, dieu tri khing sinh, theo ddi benh nhan sau 6 thing thay tinh trang tai cho 6n dinh, cic chi sd can lam sing khdng thay cd dau hieu viem. Sau thay khdp lai khoing 1 thing, thiy ndng dd tai chd, sau dd viem rd, dieu tri bao tdn that bai, quyet dinh thio khdp nhan tao, dat nep chinh hinh.
Y HOC VIET NAM THANG 10 - SO 2/2010
Nlm 1980, Pellicci PM va cdng su [5]
tdng ket 110 khdp thay lai, thdi gian theo ddi trung binh 3,4 nlm, tdng sd cd 46,2% cic bien chffng nhu ldng elc bd phan khdp nhan tao, sai khdp, gay hole dat sai vi tri, nhiem khuan, cic vin de lien quan den vffng mlu chuyen gly dau chi the... trong dd nhiem khuan chiem 3,6%, Idng/sai/ gly khdp hole dat sai vi tri chiem 14% . Nam 1985, tic gil tiep tuc theo ddi nhdm benh nhin tren, dinh gia tren 99 benh nhan, theo ddi trung binh 8,1 nam, cd 29% bien chffng lien quan den cac bp phan khdp nhan tao (cup, stem, chdm), them 1 khdp (1%) bien chffng nhiem khuan mudn. Tic gil ket luan, ty le bien chffng ting len theo thdi gian theo ddi, dac biet bien chffng lien quan den cic thinh phin cffa khdp nhin tao.
Nam 2001, Andrew L. Whaley v l cdng sir [2] theo ddi 89 benh nhan, sff dung d cdi ldn, khdng xi mang. Thdi gian theo ddi sau 7,2 nlm. Ket qui dinh gia tren 82 benh nhin, bien chiing chff yeu II sai khdp 11 benh nhan (12%), liet thin kinh hdng to 5 benh nhin, nhiem khuan sau 1 benh nhan. 4 benh nhan thay lai d cdi lin 2, 7 benh nhin thay liner.
Tac gil ket luan, thay lai khdp hing vdi d cdi ldn cho kdt qui rit tdt, ty le ldng khdp thip.
Nlm 2004, Christopher M. Haydon va cpng sir [3] theo ddi 129 khdp nhin tao, sff dung stem xuong dui cd xi mlng, trong dd 97 benh nhan theo ddi it nhat 5 nlm, cd 9 1 % stem xuong dffi cdn vung. Tuy nhien, cd 4 benh nhin tai bien gay xuong trong md va 1 benh nhan chet do huyet tic phdi, 3 benh nhan bien chffng sai khdp, 2 benh nhan bien chffng stem xuong dui. Qua theo ddi cic tic gia ket luan, thay khdp lai sff dung stem cd xi mang mang lai ket qui tdt hon d ngudi gil
tren 60 tudi, chat lupng xuong kem, tudi thp
khdp cd the tren 10 nam. K\:.
Nhin chung cac nghien cffn deu thay ring, thay lai khdp hing dat ket qua ban diu rat tdt. Tuy theo tinh trang thuong tdn de cd phuong phlp phlu thuat phff hpp. Tuy nhien, sau thay lai khdp hang, ty le bien chffng ting len theo thdi gian theo ddi, chff yeu 11 bien chffng ldng, sai khdp hole ldng cic bd phan cffa khdp nhin tao.
So sinh vdi cic nghien ciiu tren, ket qua cffa chffng tdi kha quan hon. Tuy nhien vi lupng benh nhan it, thdi gian theo ddi cdn ngan, nen cic chi sd chi mang tinh chit dinh gil tdng ket ban diu. Vi vly, cin phii tiep tue nghien ciiu tren mlu ldn hon, thdi gian theo ddi dii hon, de tang tinh khach quan va khoa bpc cffa nghien cffu.
V. KET LUAN
Qua nghien ciiu 21 benh nhan thay lai khdp hing toln phan, thdi gian theo ddi trung binh 3,2 nlm (1 thing den 8 nam), dp tudi trung binh 56,4 (tff 38-77 tudi). Chung tdi rut ra ket luan sau:
Thay lai khdp hang toan phin dupc chi dinh cho nhiing trudng hpp bien chffng sau thay khdp ky dau, chff yeu 11 bien chffng Idng/sai khdp, ldng cic bd phan khdp nhin tao, nhiem khuin khdp. Phuong phap phau thuat phu thudc vio tinh trang tdn thuong, cd thd phii thay lai toln bd khdp, hole chi thay elc bp phan rieng biet.
Ket qui budc diu cd 20/21 benh nhin dat kdt qui rat tdt v l tdt, 1 trudng hpp thit bai do bien chiing nhiem khuin slu. Khdng cd cac tai bien trong md v l cic bien chffng khac sau md nhu: Idng/sai khdp, ldng cic bd phan khdp nhan tao, liet than kinh hdng to...
HOI CHAN THUONG CHJNH HINH VIET NAM • HOI NGHj KHOA HOC TOAN QUOC LAN THLf IX
Tuy nhien day mdi chi la ket qui ban diu, nghien ciiu tren mlu nhd, thdi gian ngan. Dd tang chit lupng phlu thult, phlu thuat vien can dupc tiep tuc dao tao, nghien cffu, cac phuong tien phau thuat can dupc bd sung, cin cd cic bp phan khdp nhan tao chuyen biet phu hpp vdi nhung tdn thuong cu the.
De ting tinh khich quan v l khoa bpc cua nghien cffu, can phai tiep tuc nghien cffu tren mlu ldn hon, thdi gian theo ddi dai hon.
TAI LIEU THAM KHAO
/. Allan E. Gr (2002) " Revision Arthroplasty of the Acetabulum with Restorarion of bone stock". Hip replacement, Curent trends and Controversies. 213-232
2. Andrew L. Whaley (2001) " Extra-large uncemented hemispherical Acetabular Components for Revision Total Hip
Arthroplasty ". J Bone Joint Surg Am; 83:
1352-1357.
3. Christopher M. Haydon va cong su (2004)
"Revision Total Hip Arthroplasty with use of a cemented femoral component. Results at e mean often years". J Bone Joint Surg Am;
86: 1179-1185.
4. Kenvin J. Bozic (2009) "The Epidemiology of Revision Total Hip Arthroplasty in the United States ". J Bone Joint Surg Am; 91:
128-133. V .. , v.:
5. Pellicci va cs (1985) "Long-term results of Revision Total Hip Replacement A follow- up report". J Bone Joint Surg Am; 67: 513- 516
6 Raj K. Shina (2002) "Revision of the femoral component" Hip replacement, Curent trends and Controversies. 214-259.
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