HOI THAP KHdP HOC VIET NAM: HOI NGHI KHOA HQC TOAN QUOC LAN THU IX
ITNG DUNG NQI SOI
K H 6 PVAI TRONG DIEU TRj VIEM QUANH KHdP VAI THE CO THAT BAO KHCJP. CASE REPORT
Tran Nam Chung*, Tang Ha Nam Anh**, Dinh Ngoc Minh**
TOM T A T
Muc tiiu: Bfldc dau danh gia hieu qua dieu trj viem quanh khdp vai the co that bao khdp
bang npi soi giai phdng bao khdp.
Doi tWcfng va phWdng phap: Tat ca cac benh nhan viem quanh khdp vai the co that bao khdp dflpc npi soi khdp vai giai phdng bao khdp tai khoa Chan thflOng Chinh hinh, benh vien Nguyen Tri PhflOng, thanh phd Ho Chi Minh tfl thang 12/2010 den thang 5/2011. Nghien cflu Wen cflu, md ta cat ngang.
Kei qua: Tat ca 5 benh nhan deu cd cai thien chflc nang khdp vai sau dieu trj. Oiem Constant - Murley khdp vai trfldc (28 ± 4.6) va sau dieu trj (63 ± 8.9) khac biet cd y nghTa thdng ke (p<0,05). Oiem cai thien trung binh la 35 ± 13,4. 80% benh nhan hai Idng vdi ket qua dieu trj. Khong cd benh nhan nao cd ket qua toi hOn so vdi trfldc can thiep. Thdi gian theo doi sau md trung blnh la: 12,6 ± 5,0 tuan (dai nhat la 21 tuan). Khdng cd tai bien trong cupc mo va khdng cd bien chflng trong thdi gian theo ddi sau md.
SUMMARY Background
Adhesive capsulitis (frozen shoulder) Is a common, painful, and disabling condition. It usually responds to gentle physical therapy and conservative treatment or, if that fails, to closed manipulation with the patient under anesthesia.
In some patients, however, loss of motion may be refractory to either of these treatments and an operative release may be indicated. We are
*.• Benh vien E, **; Benh vien Nguyin Tri Phuang
reporting on the technique and results of arthroscopic capsular release as a new alternative for the management of such patients.
Aim: to evaluate the efficacy of treating adhesive capsulitis of the shoulder with arthroscopic capsular release. DESIGN:
prospective, descriptive study. PARTICIPANTS:
five patients with a clinical diagnosis of adhesive capsulitis resistant to pharmacologic and physical therapy. INTERVENTIONS: Patients undenwent arthroscopic release of the capsular joint and were given an intensive physical therapy program on the first postoperative day. MAIN OUTCOME. Measures: All patients were evaluated pre- and postoperatively at follow-up by using the Constant-Murley system score.
Results: All patients were Improved In shoulder function Constant - Murley score. PreoperaOvely, the mean Constant-Murley score was 28 ± 4.6;
postoperatively, the mean score was 63 ± 8.9.
This gain in function score were significant (p <
0.05). Procedure satisfied 80% patients, no one's worse than before. The follow-up time mean's
12.6 ± 5.0 week(longest time: 21 weeks). There were no complications in this series.
Conclusions: These Initial results support the efficacy of arthroscopic release and rehabilitative treatment for patients with resistant adhesive capsulitis of the shoulder.
Keywords: adhesive capsulitis, frozen shoulder, arthroscopy, shoulder.
Y HOC VIET NAM THANG 7/2011 - SO OAC BIET
DAT VAN DE
Vidm quanh khdp vai (VQKV) li mdt bidu hipn didn hinh cua bdnh ly phin mdm quanh khdp. Co thit bao khdp (CTBK) li mpt b-ong bdn thd cfla bdnh ly VQKV VQKV thd CTBK hay vidm co rflt bao khdp vai, ddng cflng khdp vai li tinh trang bdnh ly phd bidn, gay dau v i ban chd van ddng khdp vai. Tai khoa Co Xuomg Khdp bdnh vidn Bach Mai, theo thdng kd giai doan 1991 2000, ty Id bdnh nhin (BN) vidm quanh khdp vai chidm 13,24% tdng sd bdnh nhan didu tri npi trfl [1]. Bdnh ly niy thudmg dap umg vdi didu tri bao tdn kdt hpp t$p van ddng nh?
nhing, ndu thit bai cd thd nan khdp vai dudi giy me. Tuy nhidn, mpt sd BN vin khdng cii thipn van dpng vdi nhiimg bidn phip didu trj trdn. Trong trudmg hpp dd, BN dupe chi djnh phiu thuit giai phdng bao khdp vai. Giii phdng bao khdp vai bing npi soi khdp di dupe nghidn curu va ip dung khi rdng rai trdn thd gidi va dupe coi nhu la mdt hipn phip dieu trj hflu hipu cho nhflmg trudng hpp niy [2] [4] [6]. CJ Vipt Nam, ttong khoing 5 nim bd Ijii day, k>^ thuat npi soi khdp vai da dupe phit tridn vi flng dung rpng rai. Trong dd.
Khdp vai li khdp di ddng nhit co thd, cau tao bdi nhidu thanh phan phflc tap cho phdp thuc hidn nhidu ddng tic, vdi bidn dp van ddng rit ldn. Nhd vay, cinh tay cd thd xoay theo 3 chidu trong khdng gian, dd li cic ddng tic dua ra trudc, ra sau, ldn trdn, giang tay, xoay trong, xoay ngoii.
Khdp vai li mdt khdp ldn, gdm nhieu khdp tham gia. Khdp vai (d chio - cinh tay) dupe bao bpc bdi mdt bao khdp rit long ldo, rpng, dupe ting cudng bdi mdt sd gin co.
Diy chinh li phin bj tdn thuong trong VQKV. Phin niy bao gdm: phin co - xuong d ndng, co delta d phia ngoii, mdm ciing vai vi diy ching ciing - qua d trdn. Phin co - gin d siu: dupe tao bdi mu gin co quay ngin cfla vai, cd gin co nhj diu dii di ngang qua.
Mu cic gin co quay ngin thuc su li mdt
"phin ndi" cua xuong cinh tay trong d chio cfla xuomg bi. Mu niy dupe ciu tao bdi cic gin: gin frdn gai d trdn, gin co nguc nhd vi gin CO dudi gai d sau, gin co dudi vai d trudc dudi. Cic gin niy tip hprp \^i vi dupe dinh mpt cich ch^t chd vio c\rc trdn cfla bao khdp. Gifla cac ldp ndng vi sau li cic tfli thanh m?ic nhim giflp cho cic thinh phin cua npi soi khdp vai giii phdng bao khdp dupe khdp vai di chuydn, trupt ldn nhau de dang:
flng dung dieu trj cho cac frudng hpp VQKV tfli thanh mac dudi mdm cflng vai, dudi co thd CTBK dip flng khdng tdt vdi cic hipn delta, dudi mdm qua,...[1]
phip didu bi bao tdn. Diy ching d chio - cinh tay: li nhdm Chung tdi tidn hanh nghidn cum "iTng diy ching nim trong bao khdp, di tfl d chio dyng ndi soi khdp vai trong didu tri vidm den diu b-dn xuong cinh tay, gdm cic diy quanh khdp vai thd co thit bao khdp. Case ttdn, gifla, dudi.
report" nhim muc tidu: Bao khdp di tfl gd d chio ddn cd giii Nhdn xet hiiu qud budc ddu ciia phau (dudng noi gifla miu ddng ldn vi miu phuang phdp npi soi khdp vai trong diiu trf dpng nhd cfla xuong cinh tay).
viem quanh khdp vai thi co thdt bao khdp. Mpt so d§c diem ve viem quanh khdrp vai the co thit bao khdp:
VQKV thd CTBK hay vidm co rflt bao khdp vai la mdt tinh trang bdnh ly thudng gap, inh hudmg tdi 2-5% din sd ngudi ldn I. TONG QUAN
Giai phau \k sinh ly cua khdrp vai
HOI THAP KHdP HOC VIET NAM: HOI NGHI KHOA HQC TOAN QUOC LAN THlT IX
ndi chung v i ldn tdi 20% d BN dii thio dudng. Thuat ngfl "vidm co rflt bao khdp"
dupe Neviaser sfl dung tfl nim 1945 dd md ta tinh trang dau cflng khdp vai. Codman sfl dung thuit ngfl "khdp vai ddng lanh" (frozen shoulder) dd md ta tinh trang dau khdp vai ting din kdm vdi cflmg v i khd nim nghieng ben dau khi ngfl. Tuy nhidn, ngudi diu tidn md ta tinh trang nay la tic gia Duplay vao nim 1872 bing thuit ngu "vidm quanh khdp vai - cinh tay". Ddn nay, nhumg thuit ngu niy dupe sfl dung vdi nghia tuomg duong nhau. [2]
Nguyin nhdn gdy dong cimg kh&p vai:
Hidn tupng ddng cumg khdp vai Ii do co thit bao khdp (vidm bao khdp co thit), bao khdp ludn day nhu bia cac tdng, dan den giim van dpng khdp d chio - cinh tay. Day la h?iu qua ciia sir rdi l o ^ thin kinh dinh dudng lan tda. Ddng cumg khdp vai thudng xay ra a ngudi cd co dja cing thing thin kinh. Ddng cflng khdp vai cung cd thd g|p trong nhflmg nguydn nhin gay dau do logn duomg cua chi trdn nhu: tdn thuong do chin thuong khdp vai, bit dpng bing bd bdt keo dii, nhdi miu co tim, dau thit nguc ning, vidm ming ngoai tim, lao phdi, ung thu phdi, liet nfla ngudi, bdnh Parkinson, u nao, dau than kinh cd canh tay, zona cd cinh tay, cudng giip t r ^ g , dai thao dudng, gflt, diing cac thuoc nhu INH, phenobarbital, khang giap b-ang tdng hpp val'^'.[l]
- Chdn dodn vd diiu tri:
Vidm CO rflt khdp vai la mpt chin doan lam sang dua trdn tidn sfl dau khdp vai kdo dai kem theo tinh trang ban chd van dpng ting din ca van dpng chfl dpng va thu dpng khdp vai. Ndi h^X nhat li ban chd v|in dpng xoay ngoai.
Bdnh chfl ydu gap d lfla tudi trung nidn va thudng dien bidn qua ba giai doan: giai doan mpt la giai d o ^ dau, kdo dii tfl 3-8 thing vi theo sau dd la giai doan cumg hay
"giai doan co rflt" tidn tridn, didn hinh la kdo dai tfl 4-6 thing. Giai doan cudi cflng la giai doan hdi phuc din tim van dpng thudng keo dai khoang 5-24 thing.
Nhidu bidn phip didu trj da dupe ap dung cho tinh trang nay nhu: nghi ngoi, thudc (giam dau, gian co van, chdng vidm khdng steroid), tap van dpng chfl ddng vi thu ddng, vat ly trj lieu, udng va tidm corticosteroids, kdo giin bao khdp, nin khdp dudi giy md va npi soi giai phdng bao khdp.
Phin ldn BN cd dip umg vdi cac bidn phip didu tri bao tdn, tuy nhidn thdi gian cii thidn tridu chumg thudmg keo dai. Mpt sd BN khdng thd phuc hdi hoan toan tim v|ui dpng cua khdp vai, thgm chi khdng dap umg vdi didu trj khidn cho chit lupmg cupc sdng cua BN bj anh hudmg rat nhidu. [5] [6].
N6i soi giai phong bao khdp vai
Npi soi khdp vai lin diu tidn dupe flng dung trong didu trj ddng cumg khdp vai vao nam 1991 [2]. Tfl dd, ky thuit niy d i dupe ip dung rpng rai va dupe thfla nhin cd hipu qui.
Ndi soi giai phdng bao khdp vai cd uu didm li giflp ban che lire tic ddng va lire xoin ldn chdm xuong cinh tay nhu khi thuc hipn phuong phap nin khdp vai dudi giy md, ddng thdi cho phep chin doan va didu trj cac bpnh ly npi khdp va dudi mdm ciing vai kem theo trong khi npi soi, cho phep cit boat djch vidm neu cd, tranh dugc bidn chflng rich chdp xoay vi cho phdp quan sat tryrc tidp va can thiep chpn lpc, ddng thdi cho phdp giai phdng hoan toan bao khdp bao gdm ca giii phdng bao khdp sau nhim cai thipn xoay trong. Day cung la can thiep tdi thidu, it xam
Y HQC VIET NAM THANG 7/2011 • SO OAC BIET
lin, nhe nhang, an toan va BN cd thd xuit vidn sdm.
Chi dinh npi soi khdp vai gidi phdng bao khdp cho cdc trudng hap ddng ciing khdp vai: [2][4]
o Dieu trj bao tdn it nhit 3 - 6 thing thit bai.
o Dau nhidu.
o Han chd van dpng qua nhidu.
o c i n nit ngin thai gian phuc hdi.
o Tranh thdi gjan didu trj bao tdn keo dii.
Chdng chi dinh:[2][4]
o Nguyen nhan cflmg khdp d ngoii khdp: cd djnh ngoii,...
o Bat thudng giai phau xuong khdp vai nhu thoai hda khdp vai ning, hoai tfl vd khuin chdm xuong cinh tay, sau chin thuong.
o Nhiem triing: toan thin, tai cho.
o Bit thudmg, tdn thuong thin kinh vung CS cd.
o Didu trj bio tdn dudi 3 thing.
o Tdn thuong ung thu vflng vai dau.
II. DOI TU'ONG VA PHU'ONG PHAP NGHIEN CUtJ
Doi turong nghien cihi: Cic BN VQKV thd CTBK dupe ndi soi khdp vai giii phdng bao khdp tai khoa Chin thuong Chinh hinh, bpnh vifn Nguyen Tri Phuong, thinh phd Hd Chi Minh tfl thing 12/2010 den thing 5/2011.
Tiiu chudn lua chon vd logi trie BN:
tuong flng theo chi djnh vi chdng chi djnh da ndu d trong phan tdng quan.
Tidn binh NSK giai phdng bao khdp vai.
Tip phuc hdi chflc ning: tidn hinh sdm ngay sau phiu thuit, khdi dau bing van ddng thu ddng dd duy tri tim van ddng tdi da.
Theo ddi sau md: dinh gii theo thang didm chflc ning khdp vai Constant - Murley, so sinh vdi trudc khi phiu thuit.
- Bdng ddnh gid chiec ndng kh&p vai Constant-Murley: li bing diem thdng dung nhat dk dinh gii hidu qua didu tri ddi vdi bdnh ly khdp vai, dupe Hdi phau thuit vai - khuyu Chiu Au khuyen cio sfl dung. Bang dinh gii niy lin diu dupe xuit bin vao nim
1987. Bang didm dinh gii theo 4 chi tidu: chi sd dau, chi sd chflc ning, tim van dpng vi sflc manh.
Thang didm Constant - Murley dupe thidt kd vdi so didm tdi da li 100 didm.
Thang didm dau dupe thiet kd tdi da li 15 didm, vdi khdng dau dat 15 diem, vi dau nhidu, lidn tuc dat 0 didm. Chflc ning b-ong sinh boat hing ngiy dupe thidt ke tdi da li 20 didm. Cic dpng tic duoi, dang, xoay ngoii vi xoay trong, moi dpng tic dupe tdi da 10 didm (tdng cdng tdi da 40 didm). Sflc manh cfla khdp vai dupe thidt ke tdi da li 25 diem khi vEui dpng hoin toin khdng dau vi 0 diem khi ydu rd rang. [3].
- Ddnh gid miec dp hdi long cua BN dii Phirong phip nghien cihi: Nghidn cflu v&i ket qua diiu tri: 4 mflc dp.
tien cflm cit ngang. Xfl ly sd lipu bang thuit toan thdng kd y hpc.
Cic bu'dc tien hanh: Khim lim sing BN va lim bdnh in thdng nhit.
- Ch\ip MRI dinh gii tinh tr?ng co thit bao khdp va tdn thuong kdm theo (ndu cd).
+ Rdt hdi long: tridu chflng lim sang cai thidn nhidu, BN cam thiy de chju, lim vipc vi sinh boat dd ding.
+ Hdi Idng: tridu chflng lim sing cd cii thidn rd, BN cd thd lim vide, sinh boat de ding hom trudc.
HOI THAP KHCJP HOC VIET NAM: HOI NGHI KHOA HOC TOAN QUOC LAN THLT IX
+ Chua hdi long: trieu chumg lam sing cd cii thidn nhung chua nhidu, BN cdn gap khd khin trong lim viec, sinh boat.
+ Thdt vgng: tridu chflmg lam sang tram trpng hon so vdi trudc dieu trj.
Ky thuat giai phdng bao khdp vai qua noi soi:[2][4].
Dudng vdo: trudc, sau, gifla ngoai (vio mdm ciing)
Ddnh gid dudi gdy mi: tim van ddng thu dpng: nang trudc, dang, xoay trong vi ngoai d tu thd dang 0°, 90°
Khdng nin khdp vai dudi gay me tnrdc khi ndi soi khdp.
Cdc mdc gidi phdu quan trgng:
Khoang trdng chdp xoay v i bao khdp trudc, bao khdp sau, bao khdp dudi.
Cdng trudc
Hinh 1: Cic dudng vio: cdng sau (A), trudc (C) va gifla - ngoii (B).
Budc 1: Gidi phdng khodng trdng chdp xoay vd bao khdp trudc:
Camera vio tfl cdng sau.
Kim tuy sdng 18G vao khoing trdng chdp xoay.
Carmula vao cong trudc + ddt giii phdng khoang trdng chdp xoay.
Bat dau giai phdng tfl day ching d chio - cinh tay trdn va day chang qua - canh tay. Hoan thanh khi thay day chang cflng - qua, mdm qua.
Gan nhj diu
• SGHL
hta-ailcular subscap'oiarjs tendon
MGHl
IGHLC
Hinh 2: Giai phdng bao khdp trudc
Trudc khi giai phdng bao khdp trudc, CO dudi vai phii dupe tich ra khdi bao khdp trudc. Sau dd, bao khdp trudc dupe giii phdng bing ddt tdi didm 5 gid, trinh lim tdn thuong CO dudi vai, bao gdm ca giai phdng day ching d chio - cinh tay gifla va nhanh trudc cfla diy ching d chio - cinh tay dudi.
Budc 2: Ndn dudi gdy mi: rflt camera, tidn hanh nin khdp vai duoi gay me d tu thd ning ra trudc dt tach ndt nhflng phin cdn lai cfla day ching d chio - canh tay dudi, d tu thd
Y HOC VIET NAM THANG 7/2011 - SO OAC BIET
xoay ngoii dd tach not nhumg phin cdn lai cua bao khdp tnrdc. Viec tich ndt phin cdn lai cua bao khdp dudi bing nin dudi gay md an toan hon vi bao khdp dudi doan tfl 5 gid den 7 gid cd dam rdi thin kinh, mach miu nich.
Budc 3: Gidi phdng bao khdp sau:
diing que chuydn ddi, dua miy soi vio cdng trudc trdn v i cannula vao cdng sau.
Thdng thudng, bao khdp sau vidm va co
thit ndn thudng khd quan sit. Bit diu giii phdng bao khdp sau tfl khoing tnrdc trdn khoing trdng chdp xoay din ra sau, phia sau gin nhi diu va sun vidn. Hoin tit giai phdng khi nhin thiy spi co cfla ca dudi gai d phia dudi. Dflng giai phdng bao khdp sau d vj tri 7 gid, sau do tidn hinh nin khdp vai d tu thd xoay trong dd tach ndt nhumg phin cdn lai cfla bao khdp sau dudi doan dudi 7 gid.
Brio kliCTi Mom ciuie vai
Chop xony
Scapu'n '
Smi I , •/ Tnioc
Huili 3. (jiiii plionii toan bo bao kliq:>
Budc 4: gidi phdng khoang dudi mom ciing: sau khi giai phdng toin bp bao khdp va kiem soit lai bing npi soi mi khdng dat dupe tim van ddng tdi da, cd thd do nguydn nhin hep khoang dudi mdm Cling. Tinh trang nay thudng gap d cic tmdng hop cflng khdp sau md hoac sau chan thuomg. Trong trudng hop nay, tien hinh di vao khoang dudi mdm cflng tfl cdng sau va md thdm cdng bdn - ngoai.
Diing phoi hpp may mai va miy bao d%
mii, giai phdng khoang dudi mdm cflng.
Can than trpng tranh giy tdn thuomg gin chdp xoay.
I I I . KET QUA NGHIEN CUU VA BAN LUAN Trong thdi gian tfl thing 12/2010 den thing 5/2011, tai khoa Chin thuomg Chinh hinh, bdnh vidn Nguyen Tri Phuomg, thanh pho Hd Chi Minh cd 5 BN VQKV the CTBK dupe didu tri bing phuomg phip ndi soi khdp vai dd giii phdng bao khdp. Nghidn cflu nhdm BN niy, chiing tdi thu dupe mpt sd ket qui nhu sau:
Dac diim chung:
- Dgc diim vi gi&i: 100% BN trong nhdm nghidn cflm la gidi nfl, khdng cd BN nam. Kdt qua nay phfl hpp vdi cic nghien cflu trong y vin, chfl ydu BN VQKV thd CTBK li nfl.
HOI THAP KHdP HOC VIET NAM: HOI NGHj KHOA HOC TOAN QUOC LAN THLf IX
Ddc diim vi tuoi: 100% BN cd dp tudi trdn 40, thip nhit la 47 tuoi v i cao nhat la 68 tudi. Dp tudi trung binh cfla nhdm BN nghien cflm la 57,2 ± 7,9 tudi.
Kdt qua nay phfl hop vdi cic nghien cflu trong y vin vd dp tudi thudmg gap cfla benh ly khdp vai nay la trdn 40 tuoi.
Th&i gian mdc binh: trong nhdm nghidn cflm niy, BN cd thdi gian mic bdnh ngin nhit li 5 thing, dai nhit la 15 thing. Thdi gian mic bdnh trung binh li 10,6 ±3,8 thing. Thai gian mic bdnh keo dai, dip umg chim vdi didu trj la mpt trong nhumg die trung cfla nhdm bdnh ly niy.
- Cdc yeu td nguy ca:
Bdng 3.1. Cic yeu td nguy co:
Cac yeu to nguy cO Oai thao dfldng
Tang huyet ap Benh ly tuyen giap Bien co tim mach khac
SdBN(n=5) 1 1 1 1
Ty le (O/o) 20 20 20 20
Trong nghien cflu nay cfla chung tdi cd gap mpt sd yeu td nguy co ddi vdi benh ly VQKV thd CTBK nhu: dii thao dudng (20%), ting huydt ap (20%) va mdt sd ydu td nguy CO ve tuyen giap va tim mach khic.
Mac dfl bdnh sinh cua VQKV thd CTBK cdn tidp tuc duoc nghien cflm, tuy nhidn ngudi ta nhin thay cd nhumg ydu td nguy co lim khdi phit bdnh ly nay nhu: dii thao dudng, tim mach, tuydn giip, ... Kdt qui niy cfla chflng tdi cung nhan thiy mpt sd ydu td nguy co dd.
Th&i gian theo ddi, ddnh gid sau phdu thugt: Cic BN sau khi phau thuit giai phdng
bao khdp vai dupe hudng dan tip phuc hdi tim van ddng khdp vai va tiep tuc duoc theo ddi ngoai tni. Trong nghidn ciru nay, BN cd thdi gian theo ddi sau mo ngin nhit li 9 tuin va dai nhit la 21 tuin, thdi gian theo ddi trung binh la 12,6 ± 5,0 tuin. Thdi gian dien bien bdnh va hdi phuc cfla bdnh ly VQKV thd CTBK cd die diem kdo dii, tfl tfl, chinh vi vay can theo ddi BN sau md lau dai dd dinh gii hidu qua cfla didu trj. Sau md, tridu chflng thudng cd xu hudmg cai thidn din trong khoang thdi gian vai thing chfl khdng hdt ngay.
Ket qua dieu tri:
Ddnh gid chiec ndng kh&p vai tru&c vd sau diiu tri
Bdng 3.2. Dinh gii chflc ning khdp vai trudc va sau didu trj theo thang diem Constant - Murley:
BN 1 2 3 4
Oanh gia chu'c nang Tru'dc dieu tri
27 35 22 28
1 khdp vai theo thang diem Constant - Murley (diem) Sau dieu tri
69 49 72 63
Mure do cai thien 42
14 50 35
Y HOC VIET NAM THANG 7/2011 - SO OAC BIET 5
Trung blnh P
28 28 ± 4,6
62 63 ± 8,9
<0,05
34 35 ± 13,4
Oiim 80 70 60 50 AO
30 20 10 0
-f
1TnitK dliu tr| Sau a&u tr)
Biiu do 3.1. Danh gii chflc ning khdp vai tnrdc vi sau didu trj theo thang didm Constant Murley
Ap dung thang didm Constant - Murley, chung tdi nhin thay chflc ning khdp vai tmdc khi dieu trj cd so diem cao nhit li 35, thap nhit li 22 trong tdng sd 100 didm. Didm tmng binh chflc ning khdp vai trudc didu tri la 28 ± 4,6. Sau khi dieu trj, chflc ning khdp vai da dupe cai thipn so vdi trudc dd, sd didm chflc ning khdp vai trung binh li 63 ± 8,9 didm. Sir khic biet niy cd y nghla thdng ke vdi p< 0,05.
Sd diem chflc ning khdp vai cii thidn so vdi trude dieu trj trong nghien cflu niy cfla chflng tdi trung binh li 35 ± 13,4 (thip nhit:
14, cao nhit: 50), thip hom so vdi 48 didm (thap nhit: 13, cao nhat: 77) trong nghidn cflu cfla Warner vi cdng s\r. Tuy nhidn, nghidn cflu cfla Warner cd thdi gian theo ddi sau md kdo dii hon, trung binh li 39 thing.t7].
Ddnh gid miec dp hdi long cua BN doi v&i vi$c dieu tri:
Bdng 3.3. Dinh gii mflc dp hii Idng cfla BN ddi vdi vide didu tri:
Mfl'c do hai long cua BN Rat hai Idng
Hai Idng Chfla hai Idng That vong Tdng
SoBN 1 3 1 0 5
Tvle(o/o)
20 60 20 0 100
HQI THAP KHdP HOC VIET NAM: HOI NGHI KHOA HOC TOAN QUOC LAN THlT IX
Trong nghien cflu nay cfla chiing tdi, 80% BN hai Idng vdi kdt qui didu bi (20%
rit hii Idng, 60% hai Idng). Chi cd 1 BN chua hii Idng vdi ket qua didu trj, mac dfl trieu chflng lam sang cd cii thidn, BN cd da dau, mflc dp ban che van dpng khdp vai cd cai thien, sd diem chflc nang khdp vai theo thang diem Constant - Murley cai thidn 14 diem so vdi trudc dieu tri. Khdng cd BN nao cd kdt qua tdi hon so vdi trudc didu trj.
BN chua hai long vdi kdt qui didu trj li mpt BN cd yeu td nguy co la dii thio dudng va tai bidn mach mau nao cu. Nhidu nghidn cflm trong y vin khing djnh, VQKV thd CTBK trdn ndn BN dii thio dudng thudng ed kdt qua dip flmg vdi didu tri kdm hon va cham ban. Nhumg BN niy se can nhidu thdi gian hom de dat kdt qua nhu mong mudn.
Ngupc lai, cd BN cd kdt qui didu trj rat tdt, cd BN sau 3 tuin didu trj da do dau nhieu vi cii thidn tam van dpng rit rd.
Trong nghidn cflm cfla Warner va cpng sir, kdt qua dat dupe cung rit tdt. Tit ca cac BN ddu khdng cdn dau vai hoic chi thinh thoang dau nh? khi khdp vai lim dpng tic meinh. Tham chi cd 7/9 BN la van dpng vidn cac mdn thd thao sfl dung tay nhu tennis, bai ldi, gdn,...da trd lai thi diu sau phiu thuit.[7]
Bien ehung:
Khdng gip bidn chumg nao trong nhdm BN nghien cflu niy. Khdng cd nhiem triing vet md hay tai bidn tdn thuomg thin kinh. BN dupe hudng dan tap luyen sau md tai bdnh vipn vi ra vidn sau 2-5 ngiy.
iV. KET LUAN
Qua budc diu nghien curu 5 BN VQKV the CTBK dau tidn dupe ip dung phuang phap npi soi giai phdng bao khdp vai tai khoa Chan thuong Chinh hinh, bpnh vidn Nguyen Tri Phuong, thanh phd Hd Chi Minh, chflng toi nit ra kdt luan nhu sau:
1. Ket qua dieu tri:
Tat c i cac BN ddu cd cai thidn chflc nang khdp vai. Chflc nang khdp vai theo thang diem Constant - Murley tang ldn sau didu trj trung binh 35 ± 13,4 didm (thip nhit:
14, cao nhit: 50). Khac bidt giua diem chflc ning khdp vai trudc va sau didu trj cd y nghia thdng ke vdi p<0,05.
80% BN hai Idng vdi kdt qua dieu trj (20% rit hai Idng, 60% hai Idng).
2. Thdri gian theo doi sau mo: trung binh li 12,6 ± 5,0 tuin (dai nhit li 21 tuin).
3. Bien chumg: Khdng cd tai bidn nio xay ra trong phiu thuat. Khdng cd bien chflng trong thdi gian theo ddi sau phiu thuat
TAI LIEU THAM KHAO
1. Nguyen Thj Ngoc Lan (2011). B?nh ly phdn mim quanh khdp. Benh hoc Co Xuorng Khdp Ndi khoa; Nha xuat ban giao due Vidt Nam, trang 165-187.
2. Bell JE, Levine WN (2007), Arthroscopic capsular release. Minimally Invasive Shoulder and Elbow Surgeiy; Informa; 147-53.
3. Constant CR, Murley AHG (1987). A clinical method of functional assessment of the shoulder. Clin Orthop; 214:160-4.
4. Gartsman GM (2004). Arthroscopic management of shoulder stiffness. Textbook of Arthroscopy V ed; electronic edition.
5. Imboden J, Hellmann D, Stone J (2007).
Adhesive capsulitis. Current Rheumatology Diagnosis and treatment 2"'' ed; The McGraw
Hill Companies; electronic edition.
6. Isenberg DA, Maddison PJ, Woo P, Glass D, Breedveld FC (2004). Adhesive capsulitis or frozen shoulder. Oxford Textbook of Rheumatology 3^'' ed; Oxford University Press; electronic edition.
7. Warner JJ, Alien A, Marks PH, et al.
Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder. J Bone Joint Surg Am. Dec 1996;78(12): 1808-16.
