Y HOC VIET NAM THANG 11 - SO 1/2011
DIEU TRI KHQfP GIA XlTONG DAI CHI DlfAl BANG KET HQTP XlfOfNG BEN TRONG, GHEP TUY XimNG TlT THAN VA XIAING NHAN TAO
TOM TAT
TLT thang 04/2010 den 04/2011, tai Vien Chan thu'dng Chinh hinh, BV Viet OiTc, 23 benh nhan khdp gia, khong lien xUOng chay, 3 khdp gia xUPng diji, dUdc ket hdp xUdng ben trong, ghep tiiy xUdng tU than va xu'dng nhan tao, theo doi tdi thieu 6 thang. Khong eo bien chiTng trong va sau mo. Ty le lien xUdng 100%
(26/26 benh nhan) vdi thdi gian trung binh 7 thang(3-14 thang), day la mpt phUdng phap an toan, eho ket qua tot. TCr khoa: khdp gia, khong lien xUdng, tuy xUdng, xu'dng nhan tao, ket hdp xUdng.
SUMMARY
From March 2010 to March 2011, 26 patients with nonunions, pseudarthrosis of tibia and femur shaft tx)ne were treated with intemal fixation, autologous bone marrow and artifidal bone grafting in Institute of Orthopaedic and Trauma surgery, VietDuc Hospital, with at least 6 months follow-up. None of the patients had complications in and aftEr surgery. Bone union was obtained in 26/26 of patients (100%) at an average of 7,0 months (range, 3-14 months).
Intemal fixation, autologous bone marrow and artifidal bone grafting is effective and safety method to treatment of the femur and tibia nonunions.
Key words: nonunions, Pseudarthrosis, bone marrow, artificial bone graft, internal fixation of bone.
I.
DAT VAN DEkhdp gia, khdng lien than xu'dng dai la mot di chutig thu'dng gap trong dieu trj gay xu'dng, do nhiJng nguyen nhan ed hoc va sinh hoe khae nhau.
Khi dieu trj cac tac gia thu'dng ket hdp xu'dng vSng chac phdi hdp vdi ghep xu'dng de dat du'dc hai nguyen tac cd ban la cd dinh tdt 6 khdp gia va kich thich lien xu'dng. De kicli thich lien xu'dng, ghep xu'dng xdp tu* than la tieu chuan vang tuy nhien ed the de lai nhu'ng bien chirng ndi lay xu'dng nhu"
dau, nhiem khuan, ton thu'dng eae nhanh than kinh...va khdng dii chat lieu trong eae khuyet hdng Icin, de lai seo; Cac xu'dng nhan tao thay the lai thieu eae te bao tao xu'dng. Tiiy xu'dng tiT than eo nguon te bao gdc va tien than tao xu'dng doi dao
\M [3], [7], ghep tiiy xu'dng tiT lihan dieu tn khdp gia la mpt ky thuat du'dc thiTc hien lan dau tien bdi Lindholm va Urist nam 1980, sau dd du'dc Connolly va Shindell bao cao 1986, iTng dung thanh cong
Wen Chan thuong chinh hinh - Benh vi§n Viet Ddc
Vu Van Khoa, Nguyen Xuan Thuy, Du'dng Dinh Toan (*) cho 18/20 khdp gia khi tiem tiiy xUdng tU than qua da va bd bpt [4], [5]. Tiiy xUdng tir than tron vdi xu'dng nhan tao se cho mdt chat lieu ghep ed dii nhu'ng u'u diem eiia mot xUdng xdp tU than: Co tinh cam irng xUdng, cd tinh dan xUdng, co eae te bao tao xu'dng va khac phuc du'dc nhii'ng nhu'de diem khi lay xu'dng xdp tir than, khdi lu'dng vat lieu lai khdng han che vdi eae khuyet hong xu'dng Idn.
TIedeman va cong sir thay phirc hdp tiiy xUdng- xu'dng khir khoang eho ket qua tu'dng du'dng vdi ghep xu'dng xdp tU than khi md d gay [8]. Nam 1999, Lane va cdng sir da gay an tu'dng manh khi ghep phirc hdp BMP va tiiy xUdng ty than dieu tn eho 68 trUdng hdp ed khuyet hdng xu'dng Idn eho ket qua lien 100%.
Tai Viet Nam, ehUa eo mdt tac gia nao nghien ciTu dieu trj khdp gia, khong lien xUdng bang ket hdp xUdng ben trong, ghep hon hdp tiiy xu'dng tiT than tron vdi xUdng nhan tao. Vi vay chung tdi tien hanh 6e tai "D/eu tri khdp gia xu'dng dai chi du'di bang ket hdp xu'dng ben trong, ghep tuy xu'dng tit than va xu'dng nhan tao" wham muc dich: Danh gia kha nang lien xu'dng eiia benh nhan khdp gia xu'dng dai chi du'di, khi dieu tn bang ket hdp xu'dng ben trong, ghep tiiy xUdng tir than va xUdng nhan tao.
II.
D 6 I TUONG VAPHUONG
PHAP NGHIENcCru
1. Ddi tu'dng nghien cufu: 26 benh nhan, gdm cd 23 benh nhan khdp gia, khdng lien xu'dng chay, 3 khdp gia xu'dng diii, dieu tn tai vien chan thu'dng chinh hinh, benh vien Viet DiTc tir thang 04/2010 den 04/2011, ed 18 nam va 8 nu', tudi 18- 40 (n=21), tuoi > 40 ( n= 5).
2. Phu'dng phap nghien cufu:
- Chuan bj benh nhan tru'dc md
- Chuan bi phu'dng tien KHX, kim lay tiiy.
Chuan bj xu'dng nhan tao: Chung tdi diing xu'dng Master- Graft ciia hang Metronic: Day la xu'dng tdng hdp gdm 15% hydroxyapatite( HA) va 85% a- triealelum phosphate(a-TCP), cd dang hat xdp cau true rong, cd tinh dan xu'dng, tao moi tru'dng thuan Idi cho cac te bao xu'dng phat trien.
Phau'thuat KHX: Benh nhan sau khi du'dc vd cam dat d tu* the nam ngira, tien hanh phau thuat 61
Y Hpc VI$T NAM T H A N G 11 s6 1/2011 bdc Id d khdp gia, thao dung cu KHX cu neu cd va
khdng dii vu'ng, lay het xd d khdp gia va lam mdi 6 gay, thong dng tiiy. Ket hdp xu'dng 6 gay bang phUdng tien KHX ben trong, nep vit, dinh noi tiiy cd chdt hoac khdng ed ehdt tiiy trUdng hdp cu the.
Ghep xu'dng nhan tao vao d khuyet xUdng sau khi da du'dc KHX.
Tien hanh ghep tiiy xUdng tir than: Dung kim chpc tiiy du'dng kinh 2.0mm, chpc vao canh chau qua gai chau tru'dc tren. Lay ra khoang 15- 30ml mau tiiy xUdng, bdm dich tiiy lay du'dc vao 6 khuyet xUdng da 6ddc ghep xu'dng nhan tao.
- Cam mau, ddng vet md.
Chup XQ kiem tra sau md.
Theo doi benh nhan sau mo. Danh gia chirc nang ehi the va kha nang lien xu'dng d khdp gia sau md djnh ky hang thang.
Ket qua dieu trj du'dc phan loai theo 4 miTc tuy theo tinh trang tai ndi lay va ghep tuy xu'dng, lien xu'dng d KG va mire dp phue hdi chirc nang:
+ Ket qua rat tdt: Ndi lay tuy xu'dng khdng dau, khong viem dd, 6 KG lien xu'dng vu'ng chac, khdng cd khuyet xu'dng, di lai binh thu'dng, khong cd ngan ehi, khdng teo cd.
-I- Ket qua tdt: Ndi lay tuy xu'dng khdng dau, khdng viem dd, 6 KG lien xu'dng vu'ng, cd the ed khuyet xu'dng nhd (du'dng kinh d khuyet nhd hdn 1/3 du'dng kinh than xu'dng d ciing vj tri) nhu'ng khdng anh hu'dng den dp vuTig eiia xu'dng, di lai binh thu'dng, ngan chi 1-2 em, teo ed khong dang ke.
+ Ket qua trung binh: Dau tai ndi lay tuy xu'dng, het viem dd, d KG lien xu'dng vu'ng, cd the ed khuyet xu'dng, di lai dau, teo ed nhieu.
-I- Ket qua kem: Dau nhieu tai ndi lay tuy xu'dng, viem dd tai phat nhieu lan, d KG khong lien xu'dng, phai can thiep phau thuat lai, di lai dau nhieu, teo cd nhieu.
Tong ket, xit ly sd lieu, danh gia ket qua, Viet bao cao.
III. KET QUA NGHIEN ClTU
3.1. Dac diem nhom benh nhan nghien cii'u.
3.1.1. Nguyen nhan chan thWdng. TNGT 21/26 benh nhan, 3 TNLD, 2 TNSH ^
3.1.2. Dac diem thu'dng ton gay xu'dng ban dau: Gay hd 19/26 benh nhan, trong do 2 gay hd dp I, 9 gay hd dp I I , 4 gay hd Ilia, 4 gay hd IIIc. Chi ed 7 tru'dng hdp gay kin.
3.1.3. Chu'c nang chi the tru'dc md:
Tru'dc md cd 9 benh nhan han che gap gdi trong dd ed 5 tru'dng hdp gap tdi da 45° Cdn 17 tru'dng hdp van ddng khdp binh thudng.
Cd 8 benh nhan han che van ddng khdp ed chan, 18 benh nhan van ddng binh thu'dng.
Cd 6 benh nhan ngan chi l-2cm, edn 20 benh nhan dp dai chi binh thu'dng
3.1.4 Trieu Chung cd nang trWdc md: 100%
tru'dc mo di lai dau, cd trd dd 1 hoac 2 nang.
3.1.5.Thdi gian td khi chain thu'dng den khi md ghep xu'dng, Du'dc md tru'dc 12 thang (n=16), tir 12- 24 thang (n=7), sau 24 thang (n=3). Trung binh 11,9 thang.
3.1.6. Tien sdviem dd. 8 benh nhan ed tien sir viem dd tru'dc md da du'dc dieu tri dn djnh.
3.2. Ket qua
3.2.1. Thdi gian tu'khi md den khi ty chan mdt phan trpng lu'dng cd tiie (^iivq bang 2 chan, di t>ang 2 nang t / ngdn chan): Ty mpt phan trong lu'dng sau md < 1 tuan (n= 8), tir 2-3 tuan (n= 15), sau 4-5 tuan (n= 3), trung binh 2,4 tuan.
3.2.2. Thdi gian tu' khi mo den khi ty hoan toan (di lai tiT do khdng can trd 6^). Ty hoan toan sau md 5-8 tuan (n=18), sau 9-12 tuan (n= 5), > 12 tuan (n=3), trung binh 7,5 tuan.
3.2.3. Trieu chu'ng cd nang sau md. Cd 21 tru'dng hdp khdng dau sau mo, cdn lai 5 benh nhan dau khi di lai nhieu, trieu chirng nay mat di sau khi kiem tra cd can xu'dng rd 6 khdp gia.
3.2.4. Thdi gian xuat hien cale xu'dng dd2 \ Thdi gian
SolUdng
< 4 tuan 0
5-8 tuan 20
tren phim XQ (cd cau <
9-12 tuan 5
cale md tai 6
> 12 tuan 1
gayy.
Tong so 26 3.2.5. Thdi gian xuat hien cale xu'dng dd3 tren phim XQ( cale xu'dng nhin rd lap dSy dgay).
Thdi gian SdlUdng
< 3 thang 1
4 thang 4
5 thang 5
6 thang 4
7 thang 2
> 7 thang 10
Tong 26 3.2.6. Kha nang va thdi gian lien xu'dng. 26 benh nhan deu dat du'dc lien xu'dng, thdi gian lien xu'dng trung binh la 7 thang (3-14 thang).
3.2.7. Cac bien chu'ng trong va sau md: Khdng cd bien chuTig nao xay ra trong va sau mo nhu':
Chay mau, nhiem khuan, gay xu'dng, viem dd, gay phu'dng tien ket xu'dng...
62
Y HOC VIET NAM THANG 11 - SO 1/2011 3.2.8. Ket qua chung sau mo:
Ket qua Rat tot 17
Tdt 6
Trung binh 3
Kem 0
Tong sd 26 IV. BAN LUAN
Nhom nghien ciru gom 26 benh nhan, thdi gian tir khi bj tai nan den khi dUdc md lan nay trung binh 11,9 thang, ket qua eiia chiing toi tu'dng du'dng vdi cae nghien ciru eiia eac tac gia khac [2], [7], trong thdi gian nay benh nhan da trai qua rat nhieu lan dieu tn vdi nhieu phUdng phap khae nhau, tao ganh nang kinh te eho gia dinh va xa hdi.
Nhdm nghien ciru gdm rat nhieu benh nhan nang, nhieu nguy ed dan den khdp gia, khdng lien xUdng: Ty le gay hd cao (19/26) dac biet ed 8 benh nhan gay hd dp I I I , trong dd eo 4 benh nhan gay hd IIIc. Hdn nu'a nhdm benh nhan cd tien sir nhiem triing, viem dd cao (8/26), eo nhieu benh nhan da md vai lan trUde dd nao viem, lay xu'dng chet, day la eac nguy cd tien an de dan den khong lien xu'dng va that bai trong dieu trj, song ket qua chiing toi dat du'dc lien xUdng 26/26 tru'dng hdp day la mpt ket qua tdt, cao hdn eiia TIedeman va cpng sir lien xu'dng 30/39 tru'dng hdp khdp gia dUde ghep chat dem xu'dng khir khoang va tiiy xu'dng t y than [8]. (P= 0,05)
Phu'dng phap dieu trj nay dat du'dc hai nguyen tac cd t)an la ket hdp xu'dng viJng va kich thich lien xu'dng 6 khdp gia. Phu'dng tien ket hdp xu'dng ciia chung tdi dimg cd the la nep vit, dinh noi tiiy cd chdt hoac khdng chdt tiiy tru'dng hdp cu the nhu'ng dam bao cd dinh viJng du'dc 6 khdp gia.
Con kich thich lien xu'dng chimg tdi cho rang chat lieu ghep ciia chiing tdi cd day dii cae tinh chat ciia mot xu'dng xdp t y than, ed tinh dan xUdng nhd vao cau true xdp eiia xu'dng nhan tao du'a vao, thanh phan cau tao ciia xu'dng master graft gom 85% o-TCP va 15% HA cau true xdp eiia vat lieu tao dieu kien rat thuan Idi de eho eac te bao tao xUdng "lam to ", khdi mau tiiy xu'dng du'a vao CO ngudn te bao tao xu'dng doi dao va cd chya nhu'ng hormon, cac chat cd tinh cam yng, kich thich qua trinh lien xu'dng dien ra thuan Idi. Hdn nCa toi cho rang phu'dng phap ciia chiing toi giiip qua trinh lien xu'dng dien ra phii hdp vdi qua trinh lien xu'dng sinh ly vi chung tdi tao lai du'dc cue mau dong d gay, ma vai trd ciia cue mau ddng trong lien xu'dng da biet den t y lau nhu' mot yeu td khdi phat qua trinh lien xu'dng sinh ly. Thyc te cho thay qua trinh lien xu'dng ciia eac benh nhan dien ra rat thuan Idi, thdi gian lien xu'dng trung binh
trong nhom ciia chiing toi la 7 thang, ket qua ciia chung toi cao hdn ciia tac gia MC. Adrrew dieu trj cho 43 benh nhan khdp gia hoac khuyet xUdng dai bang TCP khdng cd tiiy xUdng kem theo cho ket qua lien xu'dng 85% sau 12 thang, ngan nhat 6 thang.
Tat ca eae benh nhan trong nhom nghien eyu du'dc hudng dan tap luyen cae khdp lan can sdm nhat co the, thong thu'dng la sau 2-3 ngay sau md, tap dyng va di lai sdm eo trd 6d, thdi gian trung binh t y khi md den khi ty mot phan trpng lUdng cd the (dyng 2 chan, di 2 nang ty cae ngon chan): 2,4 tuan, ty hoan toan sau 7,5 tuan, day cung la mpt yeu td thuan Idi de thiic day qua trinh lien xUdng dien ra thuan Idi hdn, sdm tra benh nhan ve vdi cudc sdng sinh hoat hang ngay.
V. KET LUAN
Nghien eyu dieu tri khdp gia than xUdng dai ehi dudi bang ket hdp xUdng ben trong, ghep tiiy xUdng t y than va xUdng nhan tao la phUdng phap mdi, budc dau cho ket qua tdt. Nd khae phue 6ddc nhffng nhUde diem eiia ghep xUdng xdp t y than, nhat la vdi nhffng khuyet hdng xUdng Idn can sd lUdng xUdng nhieu. Trong tUdng lai can nghien ciTu ap dung sd lu'dng benh nhan nhieu hdn de ed danh gia chinh xac iiieu qua eiia phu'dng phap nay vdi kha nang lien xu'dng cung nhu' cae yeu td anh hUdng.
TAI LIEU THAM KHAO
1. Nguyin Manh Khanh, Nguyin Tien Binh, Nguyen Thj Thu Ha va cong su" (2008), "Ghep te bao goc tiiy xUdng ty than dieu tri khdp gia than xUdng chay". Tap chf Y DUdc hoc Quan si/, 33 (1), tr.102-107.
2. Nguyin TienVan (2008), Danh gia kit qua dieu tri cham lien xu'dng va khdp gia than xu'dng chay bang nep vit ket hdp ghep xu'dng tif than tai Benh
vien 103, Luan van tdt nghiep Bac sy chuyen khoa cafp II, Hoc vien Quan Y, Ha Npi.
3. Bhargava R. et al (2007), "Percutaneous autologous bone marrow injection in the treatment of delayed or nonunion", Indian Journal Orthopaedic, 41(l),pp. 67-71.
4. Connolly J. et al (1989), "Development of an osteogenic bone-marrow preparation", J Bone Joint Surg. Am, 71(5), pp. 684-691.
5. Connolly JF (1995), "Injectable bone marrow preparations to stimulate osteogenic repair", Clin Orthop, 313, pp 8-18.
63
Y HQC VI$T NAM T H A N G I I -SO 1/2011 Johnson EE, Marder RA (1987), "Open
intramedullary nailing and bone grafting for non- union of tibial diaphyseal fracture", J Bone Joint Surg, 69A, pp 375-380.
Liang Y., Zhang B., Lu S. (1999),
"Percutaneously injected autogenous bone marrow grafting for the management of non-union of
fractures", Chinese Journal of Orthopaedics, 19, pp. 709-711.
8. TIedeman J3, Connolly JF, Strates BS, Lippiello L (1991), 'Treatment of nonunion by percutaneous injection of bone marrow and demineralized bone matrix. An experimental study in dogs", Clin Orthop, 268, pp 294-302.
THUC TRANG KIEN THIJTC, THAI DO, THUC HANH PHONG CHONG LOET CHAN CUA BENH NHAN DAI THAO DU0NG TAI BENH VIEN OA KHOA TINH DONG NAI
Huynh Qudc Thang*,Le Van Bao**
Phan Huy Anh Vu * * * dae trirng bdi hien tu'dng tang dirdng huyet man tinh trong mau do hau qua eiia sy thieu hut hoac giam hoat tinh insulin ngoai vi hoac ca hai. [4], [3]. Hien nay, tdc dp phat trien ciia benh ngay cang tang nhanh tren toan the gidi. Ngu'di ta \ibc tinh benh nhan DTD type 2 se tang t y 120 trieu ngu'di vao nam 1997 len den 285 trieu rigu'di vao nam 2010 chii yeu d eae nu'dc Chau A [8]. To chye Y te The gidi xem OTO la mdt trong nam benh khdng lay du'dc quan tam hang dau trong chien lUdc cham sdc syc khoe edng ddng the ky 21 vi yeu td ganh nang benh ly cua nd gay ra.
Tai Viet Nam, trong nhffng nam gan day sd ngu'di mac benh OTO da gia tang mpt each nhanh chdng va dang lo ngai, ty le hien mac OTO khoang 3-4% ca biet cd ndi len den 6% [3].
Theo dy doan eiia Lien doan Qudc te benh OTO (IDF), vao nam 2025, ty le hien mac OTO ciia Viet Nam tang 48% [9].
Benh OTO ed 2 loai bien chyng: cap (it gap) va man (phd bien) [9]. Trong cac bien chyng man khdng nguy hiem den tinh mang BN thi van de loet chan OTO la mot trong nhyng bien chyng chinh va tdn kem nhat. Ty le hien mac loet chan OTO t y 4,0-10%, ty le mdi mac hang nam t y 1,0
4 , 1 % ; cd 15% BN OTO se bi loet it nhat mot lan trong ddi, nguy cd bi doan chi d cac BN OTO cao gap 15 46 lan so vdi ngu'di khdng bj OTO.
Oac biet, loet chan OTO thu'dng du'dc khdi dau t y nhffng chan thu'dng rat ddn gian, nhu'ng do sy chil quan eiia BN cong vdi sy thieu hieu biet va thyc hanh dung ve cham sdc ban chan la nhffng TOM T A T
Phong van trUc tiep ve KAP kiem soat dUdng huyet va phong chdng loet chan dai thao dUdng doi vdi 954 benh nhan (BN) dai thao dUdng (DTD) typ 2 CO tuoi (61,08±9,26), nam/nff = 1/3 va thdi gian mac benh tren 3 nam (7,33±4,65) den kham, chCTa benh tai Phong kham Npi tiet Benh vien da khoa Dong Nai (BVDKON). Ket qua: Da sd (77,46%) BN deu co KAP diing dan ve an kieng, kham benh thUdng xuyen, khong quen udng thudc va tap the due nen co ket qua khdng che dUdng huyet tdt. tuy nhien, phan Idn BN lai khong co dii kien thyc, ky nang phong chdng loet chan DTD (ty le thUc hanh chi dat tren dUdi 50%).
Tur khoa: DUdng huyet, loet chan, dai thao dUdng.
SUMMARY
Actual status of Knowledge, Altitude, Practice (KAP) about preventing diabetic foot ulcer at
Dongnai Polyclinic Hospital (2010)
Live interview on KAP glycemic control and prevention of diabetic foot ulcers for 954 diabetic type 2 patients, age (61.08 ± 9.26), male/female = 1/3 and disease duration over 3 years (7.33 ± 4.65), who are examinated and treated at the endocrinology clinic of Dong nai Polyclinic Hospital. Results: The majority (77.46%) pabents are good control glycemia(77.46%) due to have right KAP of diet, exercise, regular follow up and take medicine. However, most patients do not have enough knowledge and skills in preventing diabetic foot ulcers (practice rate is only around 50%).
Keywords: Glycemia, foot ulcers, diabetes.
I.
OAT VAN OEBenh OTO la 1 nhdm cac benh chuyen hda
* Thanh pho Ho Chil^inh; ** Hoc Vien Quan Y
***Benh vien Da khoa Dong Nai
