T A P C H I Y D a o c L A M S A N G 108 Tap 12 - So 8/2017
Nghien cmi dac diem cua khoang mo- Hoffa tren sieu am if benh nhan thoai hoa khop goi nguyen phat
Research Hoffa's fat pad characteristics on ultrasound in primary osteoarthritis
Nguyen Thi H a n h , N g u y e n V a n HiJng Trudng Dgi hpc YHd Ndi
Muc tieu: 1. Mo t i dac diem lam sang, c i n lam sang, d i e diem khoang md Hoffa tren sieu i m d benh nhan thoai hda khdp gdi nguyen phit. 2. Xic djnh mdi lien quan giQa dac diem khoang md Hoffa vdi mdt sd yeu t d lam sang, can lam sang d benh nhan thoai hoa khdp gdi nguyen phat. Ddi tugng vd phuang phdp: Mo ta cat ngang, 41 benh nhan vdi 76 khdp gdi chan doan t h o i i hoa khdp gdi nguyen phat theo tieu chuan ACR 1991 tdi kham, dieu trj d Khoa Co xuong khdp, Benh vien Bach Mai tQ t h i n g 11/2016 den t h i n g 07/2017. Kit qud: Oac diem sieu am khoang md Hoffa: Chieu sau 1,95 ± 0,27 (cm), chieu ngang 6,03 ± 0,87 (cm), dien ti'eh 5,15 ± 0,95 (cm^). Khong cd mdi tUOng quan tuyen tinh glQa chieu sau, chieu ngang va dien tich khoang m6 tren sieu am vdi diem WOMAC. Khdng cd khac biet ve chieu ngang, chieu sau, dien tich khoang md tren sieu am va mQc dp ton thQOng tren X-quang khdp gdi.
Ban/uan; Trong nghien cQu nay chung toi chQa thyc hien dQpc cac tham dd tebao va phan t d deed the d i n h gia sau hon ve vai trd khoang md d benh nhan thoai hoa khdp goi. Can nhQng nghien cQu vdi quy md Idn hdn de d i n h g i i vai tro khoang md Hoffa trong t h o i i hda khdp gdi nguyen phat. Kit ludn: Khong tim t h i y moi li^n quan giQa kieh thudc, dien tich khoang m6 Hoffa tren sieu am vdi d i i m WOMAC va mdc dp ton thUdng tren X-quang d benh nhan thoai hda khdp gdi nguyen phat.
TLr/c/joo;Thoai hda khdp gdi, khoang md Hoffa.
Summary
Objective: 1. To describe clinical, subclinical characteristics and Hoffa's fat pad characteristics on ultrasound in primary osteoarthritis patients. 2. To evaluate the relationship between Hoffa's fat pad characteritics and clinical, subclinical features. Subject and method: A descriptive cross-sectional study, including 41 patients with 76 primary osteoarthritis knees, diagnosed and treated at the Department of Rheumatology of Bach Mai Hospital from November 2016 to July 2017. Result: Hoffa's fat pad features on ultrasound were: Depth: 1.95 ± 0.27 (cm), width: 6.03 + 0.87 (cm), sagittal area: 5.15 ± 0.95 (cm=). No relationship between the depth, width and sagittal area of the fat pad on ultrasound with patients' WOMAC score was found. Similarly, no relationship between the depth, with and sagittal area ofthe fat pad on ultrasound with the severity of knee osteoarthritis on Xray, assessed by Kellgren and Lawrence grade was noted. Comment: In our research, we didn't perform laboratory investigation on cells and molecular biology. Larger studies are needed to evaluate the role of Hoffa's fat pat in primary knee osteoarthritis. Conclusion: No relationship between the sizes and the area of Hoffa's fat pad with patients' WOMAC score and severity ofthe disease on X-ray assessed by Kellgren and Lawrence grade were found.
Keywords: Osteoarthritis, Hoffa's fat pad.
Ngdy nhgn bdi: 07/8/2017, ngdy chdp nhdn ddng- 15/8/2017
Nguaiphdn hoi. Nguyen Van Hiing, Email- hungnguyenvn@gmaii com - Truang Dgi hpc YHd Noi
JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY VoM2-N=8/2017
1 . Dat van de
T h o i i hda khdp goi la mdt benh co xuong khdp thudng gap. Cd nhieu yeu t d tham gia vao benh sinh cua t h o i i hda khdp nhu gen, chuyen hda, cd hoc, sinh hpc. Ngudi beo phi cd nguy cd t h o i i hda khdp cao hdn do cd che cd hpc va do cd sy giai phdng cae adipokine tQ md m d [1]. Khoang md Hoffa nam trong khdp gdi, dUdi xUdng b i n h che, nam g i n sun khdp va mang hoat dich. Bay la noi sin xuat nhieu cytokine va adipokine cd vai trd quan trong trong cd che bdnh sinh t h o i i hda khdp gdi [4]. Khoang mo Hoffa cung dupc cho la md dem b i o ve khdp gdi khdi cac sang chan [3]. Vai trd cua khoang m d Hoffa trong eO che benh sinh cda t h o i i hda khdp gdi nguyen phat da dugc nhieu t i c gia nghien cQu. Tuy nhien, ket luan dupc dua ra tUdng ddi khic biet vdi nhQng vai trd trai ngUdc. 6 Viet Nam, vai trd sinh benh hpe cua khoang m d Hoffa trong t h o i i hda khdp cdn la mot van de it dugc quan tam. Cho den nay, ehUa cd nghien cQu nao d i n h gia sy thay doi cda cau true nay va mdi lien quan vdi eae yeu t d tren ngQdi benh t h o i i hda khdp gdi. Vi v i y , chung tdi tien hanh nghien cQu nay vdi 2 mue tieu: /. Md td ddc diem Idm sdng, can Idm sdng, ddc diem cua khoang md Hoffa trin siiu dm d binh nhdn thodi hda khdp goi nguyin phdt. 2. Xdc dinh mdi Hin quan gida ddc diem cua khoang md Hoffa vdi mdt sd yeu td Idm sdng, can Idm sdng d binh nhan thodi hda khdp goi nguyen phdt.
2. Odi tuong vd phUOng phap 2.1.D6itu'0ig
41 benh n h i n vdi 76 khdp gdi ehan d o i n thoai hda khdp gdi nguyen phat theo tieu chui'n cda Hdi
Bang 1 . Dac diem nhom bdnh nhan nghien cuTu
Thap khdp hpc Hoa Ky (ACR) 1991 tdi k h i m , dieu trj ndi tru hoac ngoai tru tai Khoa Co xUong khdp, Benh vien Bach Mai t d t h i n g 11/2016 tdi t h i n g 07/2017.
Tiiu chudn Ida chgn: Benh nhan dUpc chan doan t h o i i hda khdp gdi nguyen phat theo tieu chuan Hpi Thap khdp hpc My (ACR) 1991, ddng y tham gia nghien cQu.
Tiiu chudn logi trd. Benh n h i n t h o i i hda khdp gdi thQ p h i t do c i e nguyen nhan khic hoac benh nhan khdng ddng y tham gia nghien cQu.
2.2. PhUcmg phdp
2.2.1. Thiit ke nghien cdu: Md ta cat ngang, tCr t h i n g 11/2016 tdi t h i n g 07/2017.
2.2.2. Tien hdnh nghien cdu
Cac benh nhan tham gia vao nghien cQu dUOc tham k h i m lam sang, xet nghiem co b i n , chup X- quang khdp gdi, sieu i m khdp goi. SQ dung mot mau benh i n thdng nhat de thu thap cic thdng tin ve lam sang, can lam sang.
Sd lieu dQdc xQ ly bang phan mem SPSS 16.0.
3. K^t qua
3.1. Dgc diem Idm sang, can Idm sang, sieu dm khoang m& Hoffa
3.1.1. Ddc diem chung cua nhdm binh nhdn nghiin cdu
Gdm 41 benh nhan vdi 76 khdp gdi bj thoai hda trong dd nQ gidi chiem da sd vdi ty le 92,7%. Mdt so d i e diem cy the dupe trinh bay d Bing 1.
STT 1 2
3
4
Oac diem Tuoi trung blnh (tuoi) Thdi gian mac benh (nam)
BMi (kg/m')
Trung binh Thieu can (< 18,5) Blnh thudng (18,5-23) Thira can beo phi (> 23) Biem WOIVIAC
KetquS 63,8 ±12,1
4,7 ± 3,0 23,1 ± 3,2
3 (7,3%) 15 (36,6%) 23(56,1%) 43 ± 24,6
Nhdn xet: Thoai hda khdp gdi nguyen phat la nhdm benh iy thudng gap d dp tudi trung nien, tudi trung binh cua nhdm benh nhan nghien cQu la 64 tudi, thdi gian mac benh trung binh la 4,7 nam.
TAP CHl Y DUpc LAM SANG 108 Tap 12-Sd 8/2017
3.1.2. Ddc diem X-quang khdp gdi
Cd 58,2% benh n h i n tdn thUPng khdp gdi tren X-quang d giai doan 3 theo phan dd cua Kellgren va Lawrence, khoang 21,8% benh nhan cd X-quang khdp goi tdn thUdng d giai doan 2 va 20% edn lai t o n thUdng d giai doan 4 (ket q u i khdng dugc trinh bay).
3.1.3. Dgc diem siiu dm khdp gdi va khoang md Hoffa
Bdng 2. Dac diem sieu am khdp goi va Ithoang m d IHoffa
Dac diem Co djch i<hdp Day MHD Gai xuong Ken Bal<er
Be day sun i<hdp vi tri L (mm) Be day sun i<hdp vi tri M (mm) Be day sun khdp vi tri N (mm) Chieu sau khoang md (cm) Chieu ngang khoang md (cm) Dien tich khoang md (cm')
Tile So Ichdp (n)
58 7 65 11
TJie%
76,3 9,2 35,5 14,5
Trung binh (tiiap niiat - cao nliat)
1,9 ±0,5 (1-2,8) 2,2 ± 0,6 (1 - 3,5) 1,9 ±0,5 (1-2,9) 1,9510,27(1,29-2,7) 6,03 ±0,87 (4,24-8,28) 5,15 ±0,95 (3,21-7,78)
Nhdn xit: T h o i i hda khdp gdi bieu hien tren sieu am bdi c i c d i e diem: Cd djch khdp, day MHD, xuat hien gai xuong, ken Baker. Cac dac diem nay d nhdm benh n h i n nghien cQu lan luot la: 76,3%; 9,2%; 85,5%, 14,5%. Khoang m d Hoffa tren sieu am: Dien tich trung binh khoang m d la 5 , l c m ^ chieu ngang trung binh khoang md la 6,03 em, dp sau trung binh la 1,95 em.
3.2. Nidi lien quan giCta dgc diem khoang md Hoffa vdi mot so yeu to Idm sdng, can Idm sang cua nhdm binh nhdn nghien cdu
3.2.1. Mdi liin quan gida cdc kich thddc khoang md Hoffa vdi chisd BfAl
Chieu ngang
D Thieu can El Binh thi/dng
• Thira can b^o phi
Bieu do 1 . Lien quan giQa cic kich thQde khoang md vdi chi sd BMI
Nhdn xet: Cd sQ khac biet ve chieu ngang khoang md gida 3 nhdm c i n nang: Chieu ngang khoang m d d nhdm c i n nang binh thudng thap hon d nhdm thda can beo phi. Chieu sau khoang md d nhdm thieu can thap hon so vdi nhdm thQa c i n beo phi. Khdng cd sy khic biet ve dien tich khoang md giQa 3 nhdm (p>0,05).
JOURNAL OF 108' CLINICAL MEDICINE AND PHARMACY
3.2.2. Moi lien quan gida kich thudc khoang md vdi tuoi binh nhdn
Khdng cd sy khac biet ve chieu ngang va chieu s i u khoang m d gida eac nhdm tudi. Dien tich khoang m d d nhdm benh nhan tQ 70 tudi t r d len thap hon so vdi nhdm 40 - 60 tudi (ket qua khdng dUOe trinh bay).
3.2.3. Mdi liin quan gida kich thddc khoang md vd do ndng trin X-quang khdp gdi Chieu sau
Dien tich Chieu ngang
D Giai (3oan 4
• Giai doan 3
• Giai doan 2
Bieu do 2. Lien quan giQa kich thQde khoang md vdi do nang tren X-quang khdp gdi Nhdn xit: Khdng cd sU khie biet ve ehieu ngang, dien tich va dp sau khoang m d vdi mQc dp nang tren X- quang khdp gdi (p>0,05).
3.2.4. Mdi lien quan gida diem WOMAC vdi cdc kich thddc khoang md
Sd dung md hinh hdi quy tuyen tinh phan tich theo chieu ngang, ehieu sau, dien tich khoang m d vdi diem WOMAC cua benh nhan khdng thay cd sy khac biet cd y nghla thdng ke (ket q u i khdng dUpc trinh bay).
4. Ban luan
4.1. Dgc diem Idm sang, can Idm sang, sieu dm khoang md Hoffa cda nhom nghien cifu
Trong 41 benh nhan ed 38 benh nhan nQ chiem tp' Id 92,7%, vdi tudi trung binh 63,8, phan Idn cd tinh trang q u i can (56,1%), mdc dp i n h hUdng ehQc nang trung binh va nang vdi diem WOMAC 43 (Bing 1). NhQng dac diem nay trong nghien cQu cua chung tdi eung la nhQng dac diem thQdng gap d cac benh nhan thoai hda khdp dQpc md ta trong trongmpt sd nghien cdu khae [1 ], [8].
Chieu ngang, chieu sau, dien tich trung binh khoang m d Hoffa lan lUdt la 6,03 cm, 1,95 cm, 5,15 cm^ (Bing 2). Cic chi sd nay nay thap hon so vdi ket q u i cdng bd bdi J Diepold va edng sy [2]. Cho den nay, ehUa cd nghien cQu nao danh gia ve so do cOa khoang m d Hoffa tren ngudi Viet Nam. Do v i y , c i c ket q u i trong nghien cQu nay cd tinh chat md t i ban dau. Su khae biet ve c i c sd do eua khoang m d Hoffa trong nghien cQu cua chung tdi so vdi Diepold cd
the lien quan den kich thUde chung cua cd the gilJa hai nhdm ddi tupng vdi chieu cao, c i n nang va chi sd BMI eao hon d nhdm ngudi My.
4.2. Moi lien quan gida ddc diem khoang md Hoffa vdi mot so yeu to Idm sang, can Idm sang cua nhdm benh nhdn nghien cdu
Khoang m d Hoffa la mdt cau true giai phau cCia khdp gdi. Vai trd sinh benh hpc cua khoang md nay cung nhu md mcf ndi chung trong cic cd che benh sinh cua t h o i i hda khdp ngay cang dupc quan tam [4], Tuy nhien, vai trd chinh x i c cda khoang md Hoffa n h u t h e nao trong thoai hda khdp gdi van con chUa dupe thdng nhat. Mot sd nghien cdu thay ring thay ddi ve cau true va ehQc nang cua khoang mci Hoffa cd the la mot trong cae yeu t d i n h hudng den q u i trinh viem va tdn thUdng to ehQc trong thoai hda khdp gdi trong khi mdt sd cdng trinh khic lai cho thay vai trd tich cue cda khoang md nay trong q u i trinh tien trien benh [3], [5]. Nghien cQu danh g i i i n h hQdng cua viee glQ lai hoac loai bd khoang m d Hoffa trong phau t h u i t thay toan bd khdp goi den hieu q u i dieu trj cung cho thay ket qua khdng rd rang [8], Trong nghien cQu eua chQng tdi, chi^u ngang khoang mcf giQa cac nhdm benh n h i n co phan dp BMI khae nhau cd sU k h i c biet ed y nghla thdng ke trong dd thap nhat la d nhdm benh nhan cd chi sd BMI binh thudng. Mac du v i y , chung toi
44
TAP CHl Y Daoc LAM SANG 108 Tap 12-568/2017
khdng tim thay su khie biet ve dien tich khoang mo d eic nhdm benh nhan thieu can, binh thudng va nhdm thQa can beo phi (Bieu dd 1). Ket q u i nay cung phu hdp vdi danh gia cua Diepold va edng su [2] va cho thay chu yeu kich thudc chieu ngang cua khoang m d cd lien quan den thay ddi ve can nang d ngUdi benh.
Tim hieu ve mdi lien he gida kich thUdc va dien tich khoang m d Hoffa vdi hoat ddng chQc nang va tdn thUdng tren X-quang khdp gdi d cae benh nhan nghien cQu chung tdi thay khdng thay cd sy khac biet ve chieu ngang, ehieu sau va dien tich khoang md d cac benh nhan cd chi sd WOMAC va p h i n dd X-quang thoai hda khdp gdi theo Kellgren va Lawrence khic nhau (Bleu do 2). -Didu nay cho thay, kich thudc va dien tieh cua khoang mcf Hoffa khdng cd lien he rd rang vdi mQc dp nang cua benh c i tren lam sang va X-quang. Nhieu nghien cQu cua cac tae g i i khac nhau cho thay khoang m d Hoffa la ndi san xuat hoac la ngudn gdc cua mdt sd cytokine, adipokine, lipid mediator, c i c te bao viem va te bao gdc cd vai trd trong cd che benh sinh va tien trien cua thoai hda khdp gdi [6], [7]. NhQng nghien cdu ve md benh hpc va djnh lUpng c i c adipokine va cytokine cho thay cd sy tang len cOa cac chat nay trong khoang m d Hoffa, trong dich khdp eung nhu trong mau cua ngUdl benh t h o i i hda khdp gdi giai doan mudn cho thay vai t r d cda khoang m d nay trong qua trinh tien trien cua benh [3]. Trong nghien cQu nay, ehung tdi ehua thye hien dupc eac tham dd te bao va p h i n tQ de ed the d i n h g i i s i u hdn ve vai trd cua khoang m d Hoffa d eic bdnh n h i n t h o i i hda khdp gdi. NhQng nghien cQu vdi quy md Idn hdn, ket hdp cae danh g l i ve lam sang, sieu am, t d chdc hoc va phan tQ de cd the cd cau t r i ldi cu the hdn ve vai cua khoang m d Hoffa trong t h o i i hda khdp gdi nguyen phat.
5. Ket luan
Qua nghidn cQu dae diem sieu am khoang mcf Hoffa d benh nhan thoai hda khdp goi nguyen phat chung tdi rut ra mdt sd ket luan sau:
Cic kieh thUdc tren sieu am cua khoang mS:
Chieu s i u 1,95 ± 0,27 (cm), ehieu ngang 6,03 + 0,87 (cm), dien tich 5,15 ± 0,95 (cm=).
Cd sy khae biet cd y nghTa thdng ke ve chieu ngang khoang m d d eac nhdm benh nhan thap can, can nang binh thudng va thQa c i n .
Chua tim thay mdi tUdng quan tuydn tinh glQa kich thQde va didn tich cua khoang m d Hoffa tren sieu am vdi diem WOMAC cung nhQ giai doan t o n thQdng tren X-quang d benh nhan t h o i i hda khdp gdi nguyen p h i t .
Tai lieu tham khSo
1. Cai J et al (2015) Association between infrapatellar fat pad volume and knee structural changes in patients with knee osteoarthritis. J Rheumatol 42(10): 1878-1884.
2. D]epo}d ^ eX a\ (20)5) Sex-differences of the healthy Infra-patellar (Hoffa) fat pad in relation to intermuscular and subcutaneous fat content - Data from the Osteoarthritis Initiative. Annals of anatomy
= Anatomischer Anzeiger: Official organ of the Anatomische Gesellschaft 200:30-36.
3. Eymard F and Chevalier X (2016) Inflammation of the infrapatellar fat pad. Joint Bone Spine 83(4):
389-393.
4. loan-Facsinay, A and M Kloppenburg (2013) An emerging player in knee osteoarthritis: the infrapatellar fat pad. Arthritis Res Ther 15(6): 225.
5. Klein-Wieringa, IR et al {20^^) The infrapatellar fat pad of patients with osteoarthritis has an inflammatory phenotype. Ann Rheum Dis 70(5): 851 -857.
6. Neumann E et al (2016) Adipokines in bone disease.
Nat Rev Rheumatol 12(5): 296-302.
7 Ushiyama T et al (2003) Cytokine production in the infrapatellar fat pad: Another source of cytokines in knee synovial fluids. Ann Rheum Dis 62(2): 108-112.
8. Van B, A et al (2013) Does infrapatellar fat pad resection in total knee arthroplasty impair clinical outcome? A systematic review. Knee 20(4); 226-231.
