Y H o c T P . H d C h i M i n h * P h u B a n T a p 19 * S o 5 * 2015 N g h i e n ctru Y h o c
VI PHAU THUAT NOI CHI D U t ROI 6 TRE NHO NHAN XET KET QUA TAI BENH VIEN VIET DLfC
Nguyen Hodng Cuong*, VU Trung True*, Nguyin tiong Hd*
T O M T A T
Muc tieu: Tohg kB nhimg kii qud bu&c ddu vd kinh nghiim ti-ong phau thugt noi chi dut vcn b tii nho dtegc tien hdnh tgi khoa Phdu thugt Tgo hinh - Hdm mat, Benh viin Viit Diic.
Phuong phdp nghiin aht: Nghien cieu lioi clhi trin 12 tre nlio dudi 7 tuoi bi dut rai hoac gdn rai chi the, dugc pliau thugt noi lgi tgi khoa Phdu thugt Tgo hinh - Hdm mat, benli viin Viet Due bang ky thugt not mgdi vi phiu tie 2007 - 2014. Ddnh gid kii qud phdu thugt dm vai cdc dii therm sdhg dua trin cac ym to: phuc Hoi diuc ndng (biin do van dgng cdc khap), phuc hoi cdm gidc, khd ndng tham gia cdc hogt dong binh thieang cua dii the, thdi do ciia binh nhan ddi vai dii the noi sdhg.
Ket qud. Co 17 chi the trin 12 benh nlian (6 dii duoi vd 11 du tren) dugc plidu thugt. Cdc ton thuang d dti ti-en bao gom 2 ngon cdi, 9 ngon ddi. Co 2 binli nhdn dugc noi dong then nhieu ngon tay (3 ngon vd 4 ngon). Cdc tm thuang a chi duch bao gom: 1 ngon chan cdi, 2 fhiic hgp cdc ngon nho, 2 bdn dian, 1 cochdn. Co 14 chi the dugc noi smg (4 chi duai vd 10 chi tren), dgt 82% Kii qud phuc hoi chiic nang cua cdc chi noi song dgt miic toi vd khd Id 9/14 chi the.
Kei ludn: Mac du vi phdu thuat da co nliieu thdnh cong mrgt bgc; tuy nhiin vi phdu thugt noi dii did rai a tre nho van Id mot thadi thuc doi vdi cdc phdu thugt viin. Kit qua bu&c ddu cua phdu thugt noi lgi dii the diet rai a tre nho cua chung toi la rai ddng khich li.
Tif khoa: Diet rai dti the, tre nho, noi vi phdu.
A B S T R A C T
OUTCOMES OF REPLANTATION OF THE EXTREMITY AMPUTATIONS IN CHILDREN AT VIET DUC HOSPITAL
N g u y e n H o a n g C u o n g , Vu T r u n g True, N g u y e n H o n g H a
* Y H o c TP. H o Chl M m h * S u p p l e m e n t of VoL 19 - No 5 - 2015:189 - 1 9 3
Objective: Replantation of amputed extremities lias gained a bt of successes However, microsurgery in children still now are challenges. The purpose ofdiis study is to report our preliminary outcomes and experiaices cf replantation ofthe extremity replantations in diildrai at Viet Due Hospital
Methods: Retrospective study of 12 children (under 7 years old) with complete or incomplete amputed extremities from 2007 to 2014. They were replanted at the Department of Maxillofaaal and Reconstiiictroe surgery, Viet Due University Hospital. The evaluation of postoperative functional result bases on: rehabilitation (total active motion), recovery of sensitivity, the ability of surviving extremities to perfbrm daily tasks, tlie patients and their family's satisfation with the surviving extremities.
Results: 12 patiaits wiih 17 amputed parts zoere replanted (6 lower and 11 upper exti-anities), 14 amputed parts loere successful (82%). The combined postoperative functional outcomes as good or fair zvere 9/14 parts.
Conclusions: Although microsugery has gained a lot of successes. Hozoeva; microsurgical replantation of amputed extremities in childrai still now are diallaiges. Our result in replantation ofthe extremity replantations
* B?nh vien Viet Dire
Tdc gid lien he: BS Nguyin Hoang Cuong DT: 0967273866 Email: [email protected]
Chuyen De Ngoai Nhi 189
Nghien cmi Y hoc Y Hgc TP. Ho Chi M m h * Phu Ban Tap 19 * So 5 * 2015
in children is very encouraging.
Keywords: Extremities amputation, children, replantation.
D A T V A N D E
E>ijt red chi the ngay cang hay gap trong xa hoi phat tri&i. Cac nguyen nhan chii yeii van la do tai nan sinh hoat, bao Iyc; n^jai ra con co the do tai nan lao dpng, tai nan giao thong. Hau qua ton thuong khong qua nang he den tuih mang benh nhan, nhung lai gay anh huong den chiic nang va th&i my, d^c biet la 6 tre nho truoc tuoi di hpc (duoi 7 tuoi), vi day la do tuoi ma ca the dang phat trien trong do co co quan van dpng.
Trong vai thap ky gan day, sii ra doi cua vi phau thuat da lam thay doi thai dp dieu tri doi voi loai ton tiiuong nay. TiJ nhung ca phlu thuat dau tien voi Malt va McKhann noi thanh cong canh tay cua 1 thieu nien nam 1%2, Komatsu va Tamai noi lai ngon cai diit roi nam 1965. Ke tu do den nay, noi lai chi the dut roi duoc xem nhu la 1 phuong phap dieu tri chuan mu»5^'. Noi lai chi the diit roi da tro Ihanh phau thuat thuong quy tai cac trung tam vi phau tiiuat a Viet Nam ciing nhu tren the gidi voi ti le thanh cong cao'-'-*-^^. Voi su cai thi^n trong ca ky thuat lan dung cu vi phau thuat hien dai, viec noi lai cac phan chi the co kich thuoc nho nhu blip ngon ding CO the thuc hien dupc.
Ton thuong dut roi chi the 6 tre nho kha it so voi nguoi lon. Tuy nhien, khac voi nguoi lon, chi djnh noi lai chi the dut roi 6 tre nho thuong dupc dat ra trong phan lon tat ca cac trucmg hpp, trCr khi co cac chong chi dinh phau thuat di kem '^. Mpt trong nhiing nguyen nhan la do ptmn dii the diit roi ciia tre nho sau khi noi lai co kha nang phat trien theo tuoi va kha nang phuc hoi chuc nang, cam giac tot hon so voi nguoi lon, kha nang Ihich nghi cung tot hon. Do do, ket qua chiic nang va tham my ciia chi noi 6 tie em se tot hon nhieu so voi nguoi lon*^-". Tuy nhien, kich thuoc mach mau 6 tie nho la rat be, va phai tieh hanh tiong thoi gian ngan nhat day la kho khan va thach thiic rat ldn doi vdi cac phau thuat vien vi phau trudc moi ca benh.
Theo tim hieu y van, tai Viet Nam tiii chua CO bao cao nao ve ket qua phau thuat noi chi fhe diit rdi d tie nhd (trudc tuoi di hpc). Qua nghien Cliu nay, chiing tdi muon tong ket nhiing ket qua va kinh nghiem budc dau ciia phau thuat noi lai chi the diit rdi d Ire nhd tai khoa Phau thu|t Tao hinh - Ham mat Benh vien Viet Due.
Muc tieu nghien ciru
Tong ket nhiing ket qua budc dau va kinh nghiem tiong phSu thuat noi chi diit rdi d tie nhd dupc tien hanh tai khoa Phau thuat Tao hinh - Ham m^t Benh vi^n Vi?t Diic.
DOITUONG-FHUtlNGIHAPNGHIENaJlJ Tat ca cac truong hpp benh nhan tre nhd (dudi 7 tuoi) bi diit rdi hoac gan rdi cac phan chi the dupc phau thuat noi l?d tgi khoa Phau tiiugt Tao hinh - Ham mat, benh vi?n Viet Diic cd iing dung ky thugt noi mgch vi phau tiong thdi gian tu 2007 deh 2014 dupc tiiong ke, theo ddi va danh gia tiong nghien a i u nay. Cac truong hpp tiong lai phan chi the diit rdi nhu mpt manh ghep tu do (khong cd noi mach nuoi vi phau) bi loai tru ra khdi nghien ciiu.
Nghien ciiu hoi a i u dua vao cac du li|u lien quan den benh nhan bao gom: tuoi tac, gidi tinh, nguyen nhan (co che) ch& thuong each thiic bao quan chi the diit rdi, thdi gian thieu mau, thdi gian phSu thuat, phau thugt bd' sung sdm (thieu mau dpng mach, li mau finh mach, nhilm khuan), phiu tiiuat bo sung mupn (khuyet phan mem, ndi gan, gd dinh gan, cham lien/ khdp gia) va ket qua hoi phuc chiic nang sau mo (doi vdi cac chi the dupc ndi song).
Danh gja ket qua sau md doi vdi chi tien dupc ndi song dua vao 5 tieu chuan cua tac gia Hoang®:
Thai dp cua benh nhan va gia dinh doi vdi phan chi the diit rdi dupc trong lai
Su phuc hoi chiic nang vgn dpng so vdi ben lanh (bien dp van dpng toan bp cua cac ngdn tay
190 C h u y e n D e Ngoai N h i
Y Hpc TP. Hb Chi Minh * Phu Ban Tap 19 * So 5 * 2015 N g h i e n c u u Y hoc
- TAM; bien dp doi chieu cua ngdn cai).
S\f phgc hoi cam giac cua chi the sau n6i (nghiem phap 2 diem).
Kha nang tham gia ciia chi the sau noi tiong sinh hoat hang ngay.
Bdng 1: Ddnh gid kei qud cua chi trin nm soiig theo tieu diuan cua Hoang:
M i > c d 9
1 (RStt6t}
II cr6t)
III (Kha)
IV (Ngh^o
nan) y (Khfing hdi long)
Tldu c h u l n - TAM > 80% so v o i t)en lanh - Nghidm phap 2 diem < 1 c m - Chi n6i Iham gia thu^n \<?i mpi hoat dong hang
ngay - B#nh nhan rat hai long - TAM d?l 60-80% so v6i ben ianh
- Nghidm ph^p 2 diem £ 1,5 cm - Chi n6i c6 t h i tham gia d$ng tac c^m n i m ma
khong dau.
- B^nh nhan rat hai long - TAM dat 30-60% so voi ben lanh
- Nghiem phap 2 diem £ 2 cm - Chl n6i c6 IhS tham gia dqng t^c d m nam ma
khdng dau.
- Benh nhan hk long - TAM dat £ 30% so vd\ ben lanh
- Nghiera ph^p 2 d i l m > 2 cm - Chl n6i khang t h i tham gia dgng tac c^m n i m
- B^nh nhan v l n c h i p nhgn d u v c chi n i i Benh nhSn khfing hSi long vm chi n i i vi chi n l i
khfing c6 chCrc nSng, b| dau hoac bi di cam.
Danh gia ket qua sau mo dd'i vdi chi dudi dupc ndi sdng dua vao cac tieu chuah ciia lac gia Chen "i;
Kha nang di lai cua chi the dupc noi.
Bien dp van dpng ciia ban ngdn chan.
Kha nang hoi phuc cam giac bao v^ cua ban chan.
Bdng 2: Ddnh gia kit qud dia chi dudi noi soiig theo tieu chuan ciia Chai
Mi>cdc 1
II
III IV
Tieu chuan Dl lar binh thiro'ng Bien do van dpng cac khop gan nhu' binh thirong
Dl lai khap khieng Bien 36 van dong dat tren 4 0 % so voi binh t h u v n g
Phye h l i cam giac t i t Chi ngan, phai lot d l giay Giam cam giac, khong bj loet
Phai diing nang Ban chan khong cd cam giac, b| loet
KET QUA
Cac thong tin ve benh nhan dupc noi song phan chi tiie tiong nhdm nghien ciiu dupc thong ke tiong bang sau:
Bdng 3 STT G\&\
T u l i V j t r i C c f c h I Bao quan T.gian t h i l u mau
T.gian P thuat PT b l sung
K i t qua 1 Nam
6 Ban chan B i m d i p Sai 8h 7h C.
2 Nam
4 C l c h a n B i m d i p BOng
lOh 5h20'
C„
3 NO'
4 Ngon chan
s i c gon Sai 7h 8h30'
Cl 4 Nam 17th Ban chan
Sac gon Sai 6h 5h Cii
5 Nam
5 Ngdn tay cai
Sac gon Dung
4h 4h
HII 6 Nam
4 Ngdn tay ca
Sac gon Dung
6h 5h . Hm
7 Nir 16th Ngdn tay dai
Sacgon Dung 5h-5h, 7h, 91-
7h30' N i l gan
Hiv 8 Nam
3 Ngon tay dai
Sac gon Diing 14h, 16h, 18h
7h
HII, 9 Nam
3 Ngon tay diii
S a c g p n Dung
9h 6h
Hw G,» : Plian logi theo tieu chudn cua Chen (chi dirai). Hin z Ph
Tdng cpng cd 17 chi the noi lai tien 12 benh nhan (6 chi dudi va 11 chi tien), cd 2 benh nhan dupc ndi dong thdi nhieu ngdn tay (3 ngdn va 4 ngdn). Tat ca 12 benh nhan deu nam tiong do tud'i trudc tudi den trudng (< 7 tudi), tiong dd nhd nhat la 16 thang tudi, ldn nhat la 6 tud'i.
JI loai theo tieu chuan ciuiHoang (dii tren).
Cac tdn thuong d chi dudi bao gom: 1 ngdn chan cai, 2 phiic hpp cac ngdn nhd, 2 ban chan, 1 CO chan. Cac tdn thuong chi tren bao gom 2 ngdn tay cai, 9 ngdn dai.
Co che chu yeu gay dut rdi la sac ngpt (chiem 13/17 chi the). Trong so 4 chi the bi tdn thuong bam dap cd 2 chi the bi hoai tii sau ndi.
Chuyen De Ngo^i Nhi
Nghien o h i Y hoc Y Hoc TP. Hd Chi M m h * P h u Ban Tap 19 * So 5 * 2015
Bao quan chi the diit rdi diing phuong phap trudc khi van chuyen den benh vien dupc thuc hien d 11/17 chi tiie (64,7%). Thdi gian tiiieu mau ndng thudng ggp nhat la 6 -10 gid (9/17), tiong khi thdi gian nay dudi 6 gjd la 4/17 va tien 10 gid la 4/17. Thdi gian phau thuat trung binh doi vdi 1 chi the la 4 gid. Trong sd cac benh nhan ndi song cd duy nhat 1 benh nhan can can thiep bd sung thi 2 (ndi gan).
Tdng so chl the noi song la 14 gom 4 chi dudi va 10 chi tien (14/17 = 82%). Thdi gian theo ddi ngan nhat la 1 nam va dai rihat la 3 nam. Danh gia ket qua sau mo, ca 4 benh nhan cd chi dudi dirpc ndi sdng deu dgt logi I va II (tot va kha).
Trong 10 chi tien dupc noi sdng tlu chi cd 1 ngdn tay cai la cd ket qua tot (loai II), 4 ngdn tay dgt loai HI (kha) va 5 ngdn tay dat loai IV (ngheo nan). Tdng hop cd 9/14 chi the noi song dat ket qua chiic nang logi tot \'a kha.
BAN LUAN
Muc dich cua phau thugt tiong lgi chi the diit rdi la phuc hoi toi da chiic nang va hinh thai tham my cua chi the ma tiong dd phuc hoi chiic nang dupc xem la uu tien hang dau P*.
Vi#c ndi chi the d tie nhd van ludn khd khan va la thach thiic ldn doi vdi cac phau thuat vien do dudng kinh mach mau nhd va nguy co tSc mach hogi hi cao ciia cac chi noi sau md, thdi gian phau tiiuat keo dai anh hudng den hoi siic sau md, tham chi so Iupng mau mat di tiong mo cho dil la it cQng cd nguy co de doa tinh mang ciia benh nhi. Day dupc coi la mpt tiong nhiing yeu td quan tiong de quyet dinh cd noi lgi chi the bang ky thuat vi phau hay khdng.
So vdi chi tren thi chi dinh noi lgi chi dudi diit rdi cd phan han che hon do ty Ie cac bien chiing aia ndi chi dudi thudng cao hon (tac mach, hoai hi, nhiem khuan, chgm Hen, khop gia)'". Doi vdi da so cac phau thuat vien thi ton thuong diit rdi chi dudi thudng xii ly mdm cut do viec tap phuc hoi chiic nang cho chi the sau nd'i mat rat nhieu tiidi gian va ket qua han che (teo co, co riit co, aing khdp) Hon
nUa, su tien bd cua ky thuat san xuat chan tay gia gan day da cd nhieu budc tien vuot bgc vdi cac bd phan thay the cd the dap iing td't nhiem vu<^'. Tuy nhien, viec ap dung chan tay gia cho tie nhd dudng nhu la khdng phu hop do khdng thich nghi dupc vdi tie dang tiong giai dogn phat trieh nhanh chdng. Do do, viec noi lgi chi the diit rdi d tie nhd van dupc cac tac gia uu tien lua chpn.
Thdi gian tap luyen hoi phuc chiic nang theo tac gia Hoangf'' dupc bat dau vao ngay thii 8 va keo dai 6-9 thang sau md', nhung do la ddi vdi benh nhan ldn tudi. O nhdm benh nhan oia chiing tdi kho cd the tap phuc hoi chiic nang sdm do tie quay khdc, khdng hpp tac. Ben canh do, cha me tie van chua hie'u dupc tam quan trpng ciia viec tap luyen sau md tiong viec cai thien ket qua nen cung khdng ti'ch cue tap luyen cho con sau khi ra vien. Viec tap luyen dupc bat dau vao ngay thii 14 va keo dai 12 thang sau md.
Vi?c danh gia su hoi phuc cam giac bang nghiem phap 2 diem hoac thii nghidm dap ling vdi nhiet dp (ndng/lanh) deu rat khd dupc thi^c hi?n mdt each chinh xac d tre nhd do su han che trong viec giao tiep vdi bac sy. Trong nghien ciiu ciia chiing tdi, tieu chuah nay cung chi dupc danh gia mpt each tuong doi, nhat la d cac tie be.
Hoat dpng chiic nang ciia ban ngdn tay rat phiic tgp, cd su phoi hpp chgt che giiJa cac ddng tac n#n rat khd danh gia chinh xac dupc tung chiic nang rieng re. Them vao dd, chi the diit rdi dupc ndi lai khdng the dat duoc chiic nang hoan hao gidng nhu trudc khi bi tdn thuong nen viec danh gia ket qua chiic nang sau mo vln cdn la mdt thach tiiiic ddi vdi cac phlu thugt vien. Tac gia Hoang P> da de xuat phuong phap danh gia ket qua ciia chi ndi dua tren 4 muc dich chinh ciia phau thuat la: cam nhan chii quan cua b?nh nhan, miic dp phuc hoi chiic nang van ddng, miic dp phuc hoi chiic nang cam giac va kha nang tfiam gia ciia chi ndi vao cac hoat dpng lao dpng hang ngay. Miic dp phuc hbi chiic nang
192 Chuyen D e Ngo^i N h i
Y Hpc TP. Hb Chi Minh * Phu Ban Tap 19 * So 5 * 2015 Nghien cmi Y hpc
sau md ciia dii noi khi danh gia dupc so sanh voi ben lanh. Chiing tdi ap dung tieu chuan ciia Mc gia nay de danh gja ket qua ndi chi tien. Thai dp cija benh nhan va ngudi nha ciing chi la heu chu&i cd tinh tuong ddi nhung ciing da dupc mpt sd tac gia su dung de danh gia ket qua sau mb(^-'5.
Cd 1 benh nhan nhd tudi nhat tiong nghien Cliu nay (16 thang tudi), den vdi chung toi tuong ddi sdm sau tai nan (2 gid) vdi tdn thuong diit rdi 4 ngdn tay ngang khdp ban ngon. Kiem tra tai phong md, cac dpng mach gan ngdn chung da tach ddng mach gan ngdn rieng nen chiing tdi quyet dinh chl ndi mach ma khdng ndi gan va than kinh de nit ngan thdi gian phau thuat. Ket qua cac ngdn tay deu song tdt, Mac du tie dupc md lai de ndi gan thi 2 nhung su phuc hoi chiic nang la rat kem, so vdi cac trudng hpp chi ndi sdng khac. Qua trudng hc«p nay, chiing tdi nit ra nhan xet la nen noi gan thi dau trong tat ca cac trudng hpp de dam bao phuc hbi chiic nang ve sau duoc tdt hon neu dieu kien gay me hoi siic cho phep.
Do dac thil ve chiic nang cua chi tien va chi dudi cd mdt so diem khac nhau, doi vdi clii dudi, yeu cau chiic nang thap hon (chu yeu la di lai) nen chiing tdi ap dung tieu chuan ciia tac gia ChenP' de danh gia ke't qua ndi chi dudi. Theo tieu chuan nay, ca 4 benh nhan cd chi dudi dupc ndi song deu dgt logi I va II.
Theo chiing tdi, ket qua nay ciing tuong duong vdi miic td't va kha neu so sanh ve phuc hdi chiic nang sau noi chi tien,
KETLUAN
Phau thuat ndi lai chi the dut rdi d tie nho la het siic y nghia nham phuc hoi lgi chiic nang va hinh the cua chi the^ tao dieu kien cho tie su phat
tiieh binh thudng ca ve the chat lan tinh tiian.
Mac du vi phau thuat da cd nliieu thanh cdng vupt bac; tuy nhien vi phau thuat noi chi diit rdi d tie nhd van la mdt thach thiic doi vdi cac phlu thuat vien. Vdi ty le chi noi song dat 82% va ket qua phuc hbi chiic nang sau md miic tdt va kha la 9/14 benh nhan, ket qua budc dau ciia phlu thuat ndi lai chi the diit rdi d tie nhd ciia chiing tdi la rat dang khich le.
TAI LIEU THAM KHAO
1 Bathston B, Tos P, Pontiiu I, Fenero S (2002) Loiver limb replantabons indicabons and a new sconng svstem Microsurgery 22(5):pp 187-192
2 Beriin NL, Tuggle CT, Thomson JG, Au A (2014). Digit replantabon in children a nationwide analysis of outcomes and trends of 455 pediatnc patients. Hmiri fN Y) 9(2) pp 244-252
3 Choi MSS, et al (2012) Trends in digital replantaticm Curr Orthop Pract, 23(4) p p 284-288.
4 Dao Van Giang (2007). Oanh gia ket qua cua p h i u t h u | t nra lai ban tay, ngon tay iJlii roi b i n g ke't qua vi phau tai b | n h vien Viet Diic tit 2005 d&i 2007 Luan v i n tot nghi?pBac sy npi tru benh vien, T n t o n g Dai hi?c Y Ha Npi 5 Hoang NT (2006) Hand replantabons following complete
amputation at the w n s t joint expenences in Hanoi, Vietnam J Hand Surg (Br), 31 pp, 9-17.
6 Kim HH, et al (2005) Rehabilitation after the replantation on a 2-year-old girl with both amputated legs. Br J Plast Surg.58(3):pp,404-408,
7 Lmdfors N. Marttila 1 (2012). Replantation or revasculansabon in;unes in children. madence, epidemiology, and outcome / Plasl SuT^ Hand Surg 46(5) p p 359-363
8 N g u y i n Viet N a m (2012) Nghien cihi giai p h l u dpng mach ban tay, ngon tay va iing dung trong trong lai ban ngon tay Luan an Tien sy khoa hpc. Hoc vien Quan Y 9 Yildirim S, Cahkapan OT, Akoz T (2008) Reconstructive
microsurgery in pediatnc populabon-a senes of 25 pahents Miavsiirgerit 28(2) p p 99-107
Ngdy nlign bdi hdo: 24/08/2015.
Ngdy phdn biin nMn xet bdi bdo: 25/08/2015.
Ngdy bdi bdo dugc ddng: 01/10/2015
Chuyen De Ngoai Nhi
