VIETNAM MEDICAL JOURNAL N°1 - OCTOBER - 2017 (51,4%), 15 benh nhan cd hach d bung (20,3%),
14 benh nhan ed djch d bung (18,9%). Ket qua nay ciia chung tdi cao hdn so vdi cac ket qua tim du'dc trong nghien cull ciia tac gia Tran Minh Phu'dng vdi 28,4% benh nhan day thanh da day, 16% cd hach d bung, 6,8% cd djch o bung[5].
Oieu nay cd the du'dc ly giai la do tnang nghien eiru cua chung tdi, tren 3/4 ngu'di benh ed giai doan benhsau giai doan I l i a , ty ie nay trong ngiiien ciTu ciia tac gia Tran Minh Phu'dng chi la tren 60%.
Chup CT- Scanner cd nhieu y nghTa trong viec danh gia tinh trang xam lan eae td chirc xung quanh va dac biet de danh gia tinh hinh di can:
gan, hach, tinh trang 6 bung, 6 phuc mac, djch...
tir do ed the dda ra sd bd phu'dng phap dieu trj cung nhd viec tien lu'dng benh du'dc chinh xac hdn[5]. Ket qua nghien culi cua chung tdi chi ra rang, kha nang phat hien hinh anh thanh da day rat cao, len tdi 94,6%, kha nang phat hien hach d bung la 61,8%. Cac ket qua nay eung du'dc tim thay tu'dng ty" trong cac nghien eiiu ciia cac tac gia Tran Minh Phu'dng va Klm Samnang [5, 7], Dieu nay gdi y rang, chup cat Idp can du'dc thiTc hien thu'dng xuyen d trong viec chan doan va phat hien sdm tinh trang di can cua khdi u.
V. K ^ Wfyti
Hep mdn vj la giai doan mudn cua ung thu*
bieu md da day, mac du trieu chu'ng thu'c the ngheo nan nhu'ng hau het benh nhan da bien doi toan trang (tinh trang thieu mau, rdi loan dien giai, dinh du'dng, suy chiTc nang than). Ket qua
cho thay ndi soi da day sinh thidt van la phi/cfng phap hu'u hieu de chan_ doan benh(vj tri ton thu'dng, hinh anh dai the, miTc do hep moti % ket qua giai phau benh). Hinh anh day thanh # day du'dc phat hien hau het tren sieu am va ct Scanner. Ngoai ra sieu am, chup CY scanner con giiip danh gia tinh trang dl can, xam lan, benli kem theo.
TAI UEU T H A M KHAO
1 . Randeep S. 3awa va David W, Mercer (201:3), Gastric Outlet Obstmctlon, Common Problem in Acute Care Surgery, lll-l^Q. '^
2. 'D^ng The Can Le Dinh Jloanh, Ta Vgn Td, Nguyin Phi Hung, Nguyen Van cKu (2002),
"Phan loai mo benh hoc ciia Ung thu" da dayl Tap dif Yhgc Viet Nam, 278, tr. 10-15. r '>
3. Pham Hoang Anh va cong siT (2006), "llrii hinh benh ung thU d Viet Nam nam 2000", Tapdv thong iin Ydddc, 2, tr, 19-26. ] 4. Ferzoco S va Soybel D (2006.), "Gastric outlet
obstnjction, peforation, andother complications of gastroduodenal ulcer. In: Wolfe M, edltor.Tlierapy of digestive disorders. 2nd ed, Philadelphia, PA:
Saunders". „ 5. Tran Minh Phu'dng (2014), Danh gia Ae? p
sdm nao vet hach D2, D3, 04 trong phau ffiuSt ung thw bieu md da day tai benh vien Viet Dab'^hi doan 2013-2014, Luan van Thac sy y hoc, Dai hoc Y Ha Npi.
b. Trjnh Hong Sdn (2001), Nghien cihi nao vet hach trong dieu tri phau tiiuat ung thu" da (fay, luan an Tien sy, Oai hoc Y Ha Noi.
7. Kim Samnang (2014), Nghien culi chan doan ^ dieu tri phau tiiuat ung thU bleu mo da day 1/3 trw va tam vi tai benh vien Viet Dut giai doan 2010 - 2013, Luan van thac s? y hoc, Bai hoc Y Ha Npi.
DANH GlA KET QUA P H A U THUAT DIEU TRI LIEN LECH NGOAl KHOT DAU DU-ffl XU-ffNG QUAY
Pham Ti^n Thanh*, Vfl Nh^t Dinh*, Nguyin Dinh Thuy**
TOIVI TAT
M^fc tiiu: Danh gia ket qua phau thu|t dieu trj lien lech ngoal khdp dau du'di xu'dng quay; nhan xet ve ehi djnh va ky thuat md. Ddi tddng. 31 BN (20 nam, 11 nu), tudi tir 17 - 70, du'dc chan doan lien lech ngoai khdp dau du'di xu'dng quay va dieu tri bang phau thuat sir dung FTKX la nep vit tai khoa CTCH, Bgnh vieri QY103 tu" thang 3/2bl2__- thang 7/ 2017.
Phudng phap. Nghien ciiU mo ta cat ngang, theo doi
*Bgnh vien Quan y 103, Hgc vien Quan y
**B$nh vien Quan y 105 Chju traeh nhi§m ehinh: Pham Tien Thanh Email; [email protected] Ngay nhan bai: 23.7.2017 Ngay phan bien khoa hoc: 5.9.2017 Ngay duyet bii: 12.9.2017
doe, thir nghiem lam sang khdng ddi ehuTig, ket hcfp hoi eiru va tieh ciTu. Ket qua: Ket qua gan: 100%BN lien vet md ky dau; Ket qua xa (Theo tieu chuan cua Fernandez D.L,) d 30 BN sau md tir 9 - 62 thang.-&D%
dat ket qua rat tdt, 23,3% tot, 16,7% trung binh^
khong cd ket qua kem. Keiluatr. Ket qua dat di/^cB kha quan, cat thien dUdc tinh trang dau va phucjiffl chirc nang van dong khdp cd tay. Chi dinh mo cl nhu'ng benh nhan cd dau, bien dang eo tay va han die van dong nhieu la thda dang, ket xudng nep vit phu hdp vdi 0 lien lech ngoai khdp.
Tdkhoa: lien lech, dSu du'di xUOng quay, ngoai khdp.
SUIVIMARY
EVALUATION OF RESULT OPERATIVE OF THE EXTRA - ARTICULAR DISTAL RADIUS
MALUNIONS
TAP CHl Y HQC VIET NAM TijiP 459 - THANG 10 - SO 1 • 2017 Objectives. Evaluation of result operative
eatment of the extra-articular distal radius lalunions; comments on technical indications and peratlons. Subiects: 31 patients (20 males, 11 jmalesl. from 17 to 70 aqes, diaanosed with extra- rticular distal radius malunions, were treated bv onlocked Plate Fixation at deoarment of orthopedic urqerv, 103 Militaiv Hospital from 3/2012 to 07/2017.
jethod. Cross sectional study, lonqitudinal monitor, linlcal without control trial, combine prospective esign and retrospective desiqn. Result: 100%
latients earlv healing. Far result fbv the standards of emandez D.L score) in 30 oatients after surgery from I to 62 months were: 60% very qcmd, 23.3% good, .6.7% average, 0% poor. Condusion: achieved positive esults, relief from pain and restore fundjon of carpal snts. Detomination of condudina suraerv fbr oatients wth wrist pain or deformation and reducinq exercise is easonable, connectinq bone fastened with bold suitable Q the connector outside the loint.
Keyword: Malunions, distal radius, extra-articular .BiBLTVANDE
Lien lech la bien chu'ng phd bien nhat trong ac bien chirng gay dau du'di xu'dng quay, chiem Jioang 23% ddi vdi dieu trj bao tdn va 1 1 % vdi iieu trj phau thuat [6]. Lien lech dau du'di xu'dng ]uay ed the gap lien lech ngoal khdp hay pham chdp. Su" pho bien ciia lien lech ngoai khdp so 'di lien lech pham khdp du'dc nhiiu tae gia xem ihu" la mdt dac diem eiia lien lech dau dddi tu'dng quay [2], [4], [ 5 ] . Ring D. va cdng siT [5]
)iai thich sy" phd bien nay chu yeu do gay xu'dng igoai khdp phd bien hdn gay xu'dng pham khdp.
*lcit khac do ket qua diSu trj lien lech pham khdp Jiirdng It kha quan nen cac cd sd y te rat han :he thu dung dieu trj loai lien lech nay. Lien lech Jau du'di xu'dng quay gay dau, han che van Jong cd tay, giam sii'e nam, anh hu'dng tdi eude jong, sinh hoat, tham my ciia ngu'di benh. Mac JLI khong cd chi djnh bat budc phai can thiep 3hlu thuat dieu trj lien lech dau du'di xu'dng luay nhu'ng nhieu tac gia cho rang phau j h u a t 'In la phu'dng phap dieu trj chii yeu de giai luyet tan goc can nguyen cac trieu chiTng ciia ien lech [1], [2], [ 6 ] .
Tren the gidi trong nhu'ng nam gan day da ]hat trien nhieu phu'dng phap ky thuat due (iTdng, chinh true de gial quyet cac van de ke
;rln cua lien lech dau du'di xu'dng quay ndi :iiung hay lien lech ngoai khdp dau du'di xu'dng luay ndi rieng. Trong nUdc, niiieu cd sd da dieu Tj bang phau thuat. Tai Benh vien quan y 103 ia dieu tri cho mdt so tru'dng hdp, trong do cliu 'eu gap nhu'ng b i n h nhan lien lech ngoai khdp iau dirdi xu'dng quay sii dung phu'dng tien ket tu'dng bang nep vi't. Oe tdng ket, danh gia, nang
cao chat lu'dng dieu trj ddi vdi mat benh nay, ehiing tdi tien hanh nghien eiru nay vdi muc tieu:
Danh gia ket qua phau thuit dieu tri lien lech ngoai khdp dau dddi xu'dng quay va nhan xet ve chi dinh, ky thuat md.
II. OOI TUPNG VA PHyONG PHAP NGHIEN COU 2 . 1 . Ooi tu'dng n g h i i n cu'u: Ddi tu'dng nghien ciTu gom 31 benh nhan ddde chan doan lien lech ngoai khdp dau du'di xu'dng quay cd bleu hien lam sang dau, bien dang, ban che van ddng khdp co tay, sap/ngOra cang tay du'dc dieu trj phau thuat, sir dung phu'dng tien ket xu'dng bang nep vit tai khoa Chan thu'dng chinh hinh, Benh vien quan y 103 tir thang 3/2012 - thang 7/2017. Cac benh nhan du'dc li/a chon tir 17 tudi trd len, ed hd sd day dii va dja chi sd dien thoai lien lac.
Loai trir cac benh nhan bj cac benh ly nhu': u xu'dng, lao xu'dng, viem khdp thoai hda mire do nang d co tay anh hu'dng tdi danh gia ket qua.
1.1. Phu'cfng phap nghien cuti: Nghien ciili md ta cat ngang, theo ddi dpc, thir nghiem lam sang khdng ddi chiihg, ket hdp hdi ciTu va tien euU.
2.2.1. Nghien edu hoi edu: Truy edu benh an, thdng ke cac chi sd nghien cuVi: tuoi, gidi, dac diem LLDDXQ, thdi diem mo, ky thuat md, danh gia lam sang tru'dc mo: tinh trang dau, bien dang, chirc nang van ddng khdp ed tay, do lire nam ban tay, cac tham sd X quang, X quang sau phau thuat, dien bien sau phau thuat. -Danh gia ket qua xa ( > 6 thang).
2.2.2. NghiSn edu tiSn edu: Oanh gia tinh trang tru'dc md: miTc dp dau, bien dang, mu'e dp han che van dpng ed tay, do Idc nam ban tay, eac tham so X quang. Phan tieh lam sang va X quang, chi djnh phau thuat^ tham gia phau thuat.
Theo ddi, cham sdc sau phau thuat, chup X quang danh gia ket qua chinh siTa bien dang. Djnh ky kham va danh gia ket qua xa ( > 6 thang).
2.2.3. Dinh gia kei qui diSu tri - Danh gia ket qua gan: diTa theo dien bien vet mo, cac bien chirng sdm, ket qua chinh siTa bien dang, cac tham sd X quang.
- Oanh gia ket qua xa: Cae chi tieu danh gia bao gom; ket qua lien xu'dng, SLT phuc hoi ve giai phau, ket qua chinh sira bien dang, cac tham sd X quang, chu'c nang van dpng, tinh trang dau co tay va kha nang trd lai lam viee. Do lu'c nam ban tay bang each lay gia trj trung binh cua 3 lan do cao nhat (% so vdi tay lanh) [ 2 ] . Danh gia mii'e dp dau d CO tay theo tieu chuan cua Fernandez D.L. chia lam 4 mii'e do: rat dau, dau viTa, dau nhe, khdng dau [ 2 ] , [4].
VIETNAM MEDICAL JOURNAL N°1 - OCTOBER - 2017 - Oanh gia ket qua chung: Theo tieu chuan
cua Fernandez D.L. la he thdng cho diem hiTu I'ch ciia cd tay, ban tay, khdng so sanh vdi tay lanh, bang each cho diem theo tiTng chi tieu, du:a tren cae ehi tieu nhu': tinh trang dau co tay, bien dp gap, duoi cd t^y, bien dp sap, ngiici cang tay, li/c nam ban tay va danh gia dy^ tren tdng diem dat du'dc, chia iam 4 miTc: Rat tdt, tdt, trung binh, kem [2], [4], [5].
2.2.4. XuT ly sdi lieu: Xd ly sd lieu bang phan mem SPSS 20.0.
III. KET QUA VA BAN L U A N 3 . 1 . Dac diem benh nhan nghien cu'u 3.1.1. Die diem tudi, ff'di
Bang 1: Phin loai theo nhdm tuoi va gidi (n=31}
Nhom tuoi Tir 17- 30 tuoi
> 30 - 50 tuoi
> 50 tuoi -70 tuoi
I
(%)
Gi6i Nam
10 5 5 20 64,5%
Nu' 0 1 10 11 35,5
z
10 6 14 31 100%
(o/o) 32,3%
19,3%
48,4%
100%
Tudi trung binh tai thdi diem phau thuat la 44,29
± 17,67 tudi (17-70 tudi) Benh nhan nam gidi chiem ty Ie cao hdn nd gidi trong khi do trong nhdm tren 50 tuoi, nu' gidi lai chiem phan Idn.
Phan bd theo tudi va gidi trong cac benh nhan nghien cu'u tu'dng tu" vdi nghien ciTu ciia Tarallo L. va edng sd (2014) [7].
3.1.2. Di lech ciia doan ngoai vi Bang 2: DilSch cua doan ngoai vi (n=31) Di lech
trong mat phang
diTng doc Di lech rasau Di lech ra tru'dc
Di lech ngan xu'dng f+)
(-)
{+)
(-)
1
Di iecii trong mat piiang dij'ng
nqanq Trong i Ngoai ] Khong
0 0 __,0 _
0 0
21 0 1 10
0 0 0 0 0 31 1 0
1
21 0 10 0 31 Tir bang tren cho thay phan Idn dau ngoai vl bj di lech ra sau va ra ngoai. Tat ca cae tru'dng hdp deu di lech ra ngoal va dl lech ngan xu'dng.
Mdt sd tac gia chi ra rang di lech eiia dau ngoai vi md gde ra sau thi phd bien sau lien lech dau
du'di xu'dng quay. Cd the do bien dang di lech ra ngoai thu'dng di kem vdi gay Colles va gay SmUii nen hay gap trong lien tedi sau gay ngoai khftj.
Bien dang ngan xu'dng quay rat phd bien bed gay dau du'di xu'dng quay ludn cd siT nen ep gay ti@ii xuWng tai d gay di lech ehdng, gap goc [1], [2], [4],
3.2. Dac diem phau t h u | t
*Thdi diem mo; Trong ngliien eiTu eiia chiing tdi eae benh nhan mo trong vdng tir 4 tuan -16 tuan dau la 27/31 BN chiem 87,1%. Nhu'vay phan ldn cac BN du'dc md trong giai doan daiig can xu'dng. Theo Jupiter 3.B. va Ring D. (1996) [4] nghien ciTu so sanh giuci mo sdm va muon tropg dieu tri LLDDXQ da nhan thay thiTc hl^n md sdm - md trong giai doan ed can xUdng non thi cd nhieu ldi ich hdn khi da lien xu'dng chae.
Ldi ich ve mat ky thuat la de dang due bo c ^ xu'dng va xap xep lai cac doan gay dung vdi &
phau va khdng phai can thiep ket hdp de ctilp siTa nhuhg bien ddi ciia phan mem.
*Du'dng mo: Phan Idn BN du'dc mo vdi du'dng phia sau 21/31 BN (67,8%). Du'dng mo phu thude vao di lech eiia dau ngoai vi. Mo dudng phia tru'dc vdi dau ngoai vi di lech ra tru'dc, mo du'dng phia sau vdi dau ngoai vi di lech ra sau.
*Ky thuat can thiep vao 6 lien ISch: Pha can xu'dng, nan ehinh, phuc hoi lai hinh the giai phau: 27/31 BN (87,1%). Due xu'dng, chinh true dau du'di xu'dng quay: 4/31 BN (12,9%).
^Phu'dng tien ket xu'dng: Tat ea 31 benh nhan deu du'dc sir dung PTKX la nep vit. Vj In dat nep cung phu thude vao di lech eiia dau ngoai vi tu'dng td vdi du'dng mo.
3.3. Ket qua diieu trj
3 . 3 . 1 . K§t qua gan: Tat ca eac BN deu lien vet md ky dau, khdng ed bien chuTng sdm sau mo. Cd 31/31 BN (100%) BN tren Xquang sau md: ket xu'dng dat yeu cau, chinh sii^ het cac di lech. Oa cd SLT cai thien dang ke ve gia trj tmng binh cua eac TSXQ tai thdi diem sau md so viii tru'dc md: RI (gde nghieng quay tru eiia mat khdp xu'dng quay) tang tiT 13,1° tdi 20,41", RL (dp dai CLia mat khdp xu'dng quay) ^ng tji 7,91mm tdi 10,63mm, RT (gde nghieng ben ciia mat khdp xu'dng quay) giam tir 18,34° ve phia mu tay xuong 9,87°, UV (dp chenh quay tru) giam tiT 2,2mm xuong cdn - 0,32mm.
3.3.2. Ket qua x a ; Chimg tdi kiem tra du'dc 30/31 BN (96,8%). Thdi gian theo doi danh gi^
TB: 37,71 ± 18,79 thang (9 - 62 thang). Ket qua lien xu'dng 30/30 BN (100%) khdng cdn di l^ch, Da cd su" eai thien dang ke ve gia trj TB eiia caC TSXQ tai thdi diem danh gia so vdi tru'dc mo: RI
TAP CHl Y HOC VigT HAM TAP 459 - THAHG 10 - SO 1 - 2017 )6e nghieng quay try cua mat khdp xu'dng
jay) tang tir 13,1° tdi 20,1°, RL(dd dai eiia mat idp xu'dng quay) tang tir 7,9imm tdt 10,71mm, T(gdc nghieng ben cua mat khdp xu'dng quay) lam tCT 18,34° ve phia mu tay xuong 9,61°, UV Ip chenh quay tru) giam tir 2,2mm xuong cdn - ,i4mm. SLT phuc hdi chiTe nang van ddng trung inh eiia BN thay doi so vdi tru'dc mo la: Bien dp an ddng sap/ngiTa: tir 105,6° den 170°, bien dp i n ddng gap/duoi co tay: tCr 54,67" den 97,94°, Ighieng quay: tir 6,27° den 19,53°, Nghieng tru:
J-19,4° den 38,77°, liTc nam ban tay: tir 59,7%
;en 80,4%. Cd 86,7% BN iam viec binh thu'dng, 3,3% ban che, khdng cd BN nao phai ddi nghe lay khong the lam viec du'dc. Tinh trang dau co ay sau md cd 80 % BN khdng dau, 20% BN cdn lau la nhutig tru^dng hdp dau nhe. Cd 96,7% BN let bien dang cd tay, cdn 1/30 BN (3,3%) bien lang ed tay sau mo.
3.3.3. Ket qua c h u n g : Chiing tdi danh gia heo tieu chuan cua Fernandez .D.L
1
33.30% ^m 16.70%I I
Trung binli Kem Bleu dd 1. Danh gia kS't qua chung Tir bieu do 1 cho thay ket qua chung trong ighien ciilJ ciia ehiing tdi la: Rat tot: 60%, tdt:i3,3%, trung binh: 1 6 , 1 % , khdng c d k e t qua ffim. Ket qua chung trong nghien edu cua chung Di ty le rat tot va tdt la 83,3% tu'dng tiT vdi ket iua cua Fernandez D.L. (1982) [2] va Fok
"I.W.M va cpng SLT (2015) [ 3 ] . Cac ket qua thu lu'dc cho thay phau thuat dieu tri LLNK dau du'di (U'dng quay da cai thien rd ret tlnh trang dau.
Men dang va ban che van ddng cd tay.
V. KET L U A N
*Ve k e t q u a d i e u t r j :
- Ket qua gan (n=31): Lien vet md ky^dauja 100%, khdng cd bien chirng sdm sau mo. Tren 3him Xquang 100% benh nhan ket xu'dng dat 'eu cau, chinh siTa het eae di Idch. Gia trj trung )inh cua cac tham so X quang: RI (gde nghieng
quay tru eiia mat khdp xu'dng quay) = 20,41°, RL (dp dai ciia mat khdp xu'dng quay) = 10,63mm, RT (gde nghieng ben cua mat khdp xu'dng quay) = 9,87°, UV (dp chenh quay try) = - 0,32mm.
- Ket qua xa (n=30): Lien xu'dng chae khdng edn dl lech 100% benh nhan. Gia trj trung binh eiia eac tham so X quang: RI (goc nghieng quay tru eiia mat khdp xu'dng quay) = 20,1°, RL (dp dai ciia mat khdp xu'dng quay) = 10,71 mm, RT (gde nghieng ben ciia mat khdp xu'dng quay) = 9,61°, UV (do chenh quay try) = - 0,14 mm, Cd 96,7% benh nhan het bien dang cd tay. 86,7%
benh nhan trd lai iam viec binh thu'dng, 13,3%
lam viee han che. 80% benh nhan het dau co tay, 20% edn dau sau mo la nhij'ng benh nhan dau nhe. Ket qua chung theo tieu chuan ciia Fernandez: 60% dat ket qua rat tdt, 23,3% tdt, 16,7% trung binh, khdng cd ket qua kem.
=*=Nhan x e t vS chi d j n h , ky t h u $ t m o : Chi dinh phau thuat d nhiJng benh nhan cd dau, bien dang cd tay va ban che van ddng nhieu la thda dang. Ky thuat pha can xu'dng, nan chinh, phyc hoi lai hinh the giai phau phii hdp vdi eae tru'dng hdp lien xu'dng chu'a vdng. Ky thuat due xu'dng, eliinh true du'dc ehi djnh cho cac tru'dng hdp da lien xu'dng chae. Ket xu'dng nep vit phii hdp vdi 6 lien lech ngoai khdp.
TAI UEU T H A M KHAO
1. Bushnell B.D. and Bynum D.K. (2007),
"Malunion of the Distal Radius", J Am. Acad Ordiop Surg, 15 (1), pp. 27 - 40.
2. Fernandez D.L. (1982),"Correction of post- traumatic wrist deformity in adults by osteotomy, bone grafting, and internal fixation", 3. Bone loint Surg Am., 64, pp. 1164 - 1178.
3. Fok M.W.M., Fernandez D.L anh Hernandez L.
(2015), " A Les invasive distal radius malunited dorsally displaced extra ~ articular fracture", The Journal of Hand Surgery.,42, pp: 812 - 818.
4. Jupiter J.B. and Ring D. (1996), "A Comparison of Early and Late Reconstruction of Malunited Fractures of the Distal End of the Radius", J Bone Joint Surg Am., 78, pp. 739-748.
5. Ring D., Prommersberger KJ., Del Pino J.G., Capomassi M., Slullitel M. and Jupiter J.B.(2005),Ton'eetive Osteotomy for Intra-Articular Malunion of the Distal Part of the Radius",.^ Bone Joint Surg Am., 87, pp. 1503 -1509.
6. Sameer J.Lodha.,Robert W Wysocki. and Mark S.Cohen.(2011), "Malunion of the Distal Radius", Am Society for Surgery of the Hand, pp, 125 -137.
7. Tarallo L., Raffaele M,, Roberto A., Catani A.
(2014), "Malunited extra - articular distal radius fractures: Corrective osteotomies using volar locking plate", J Orthopaed Traumatol, 42, pp. 285 - 290.
