VIEM KHdp CAP cut; ANH SOI VA YEU

CHUYEN DJ: CO XUONG KHOP -. NHOTNG TIJN BO. i KOriG CHAN tJOAN VM UICU I m. NGHIEN c u t ; HINH ANH NOI SOI K H 6 P VA MOT SO YEU TO LIEN QUAN TRONG VIEM KHdp GOI DO NHIEM K H U A N CAP TINH Tran Nam Chung*, Nguyin Vmh Ngoc". TOM TAT Muc tieu nghien cCtu: nghien ciTu hinh anh no! soi khdp d benh nhan viem khdp gdi do nhiem khuan (VKGNK) cap tinh va mdi lien he giiJa cac giai doan npi soi vdi mdt so yeu td lien quan. Ddi tUtfng va phu'dng phap nghien ciJ'u: 30 benh nhan viem khdp gdi do nhiem khuan cap tinh dieu trj ndi tru tai khoa Cd Xuidng Khdp, benh vien Bach Mai tir 1/2006 den 9/2009 di/Oc ndi. soi khdp gdi. Nghien cu'u tien cuU ket hgp hoi cu'u, md ta cat ngang. Ket qua va Ket luan: 1, Ve hinh anh ndi soi khdp cua benh nhan VKGNK: Gap nhieu cac td'n thu'dng tang sinh mang hoat djch khdp. Tinh trang lang dpng fibrin gap d tat ca cac benh nhan trong dd 83,3% la d mu'c dp nang, Theo phan loai ciia Gachter, giai doan ndi soi (GDNS) I gap d 33,3%, 50% benh nhan d giai doan I I va 16,7% d giai doan 3, khdng cd benh nhan d giai doan ndi soi IV. 2, Khdng thay moi lien quan giii'a thdi gian mac benh, thdi gian dieu tri ndi tru tru'dc ndi soi vdi cac GDNS. Cd mdi lien quan thuan giu^ bach cau mau ngoai bien, mau lang d gid thir nhat, gid thii' hai vdj cac GDNS.. Tur khda: Viem khdp nhilm khudn, khdp gii, ndi soi khdp ABSTRACT Purpose of the study: The goal of this study was to investigate the endoscopic stages of septic arthritis and the relationship between the stages with some factors. Material and methods: Prospective and restrospective study: Thirty inpatients were treated in the Rheumatology Department, Bach Mai Hospital between 2006 and 2009 for pyogenic septic B$nh vien E, 'Benh vi?n Bgch Mai. 76. arthritis of the knee. Results: The infection was staged according to the criteria of Gachter. Stage I infection: 10/30 patients (33,3%), 50% patients in stage I I and 16,7% in stage III. There's a relationship between mean WBC, ESR with stages of infection. Key words: septic arthritis, knee, arthroscopy. I . DAT VAN DE Ngay nay, ty le tii vong va tan, phe nang do viem Ididp nhiem khuan cap tinh da giam di rat nhieu. Cd dugc dieu dd mdt phan ldn la nhd su phat triin manh me va siic manh cua thudc khang sinh. Tuy vay, cho den nay viec kiem soat hoan toan nd van cdn rat nhieu khd Jdian. Hieu qua dieu tri ciia benh khdng chi phu thudc vao sd luong hay chung loai khang sinh dugc sii dung, toan trang cua ngudi benh ma cdn phu thudc vao viec chan doan va dieu tri dugc tiln hanh chinh xac va sdm den dau. Muc dich ciia viec dieu tri khdng chi nhdm dieu tri tinh trang nhilm trimg edp tinh ma cdn nhdm bao tdn tli da chiic nang cua khdp. Chinh vi vay, ngoai viec diiu tri khang sinh hgp ly thi dan luu mu va lam sach cac t l chiic hoai tir, cac hda chdt trung gian gay viem trong d khdp la rat can thilt trong dieu tri viem khdp nhiem khudn [1][2]. Tir nam 1986, Smith MJ da iing dung ndi soi riia khdp dl dieu tri viem khdp nhiem khudn dat kit qua tot [8]. Tir dd, npi soi khdp(NSK) da dugc ling dung rdng rai trong diiu tri viem khdp nhiem khudn[5][6].. NOI KHOA - SO 4/2009 Tai benh vien B?ch Mai, viem khdp nhilm khudn chilm ty le 9,06% trong md hinh henh ly ca xuomg khdp[4]. Ndi soi khdp gdi da bude dau dugc ap dimg trong chdn doan va diiu tri viem Ididp gdi nhilm khudn (VKGNK). Chung tdi tiln hanh nghien ciiu "Nghien ciiu hinh anh ndi soi khdp va cac ylu td lien quan trong viem khdp gdi do nhiem khudn cap tinh" tai khoa Ca Xuong Khdp benh vien Bach Mai nhdm hai muc tieu: 1. Md ta hinh anh ndi soi khdp ciia benh nhan VKGNK. 2. Danh gia mdi lien quan giiia cac hinh anh ndi soi khdp gdi vdi mdt sd yeu t l lien quan. II. DOI TirgNG VA PHl/QNG PHAP NGHIEN CUtJ 2.1. Doi tUQ^ng nghien cuu Gim 30 benh nhan(BN) viem khdp gii do nhiem khudn edp tinh dugc ndi soi rira khdp tai khoa Ca Xuang Khdp, benh vien B?ich Mai tii nam 2006 din thang 9 nam 2009. • Tiiu chuin chpn bpnh nhdn: BN dugc chdn doan VKGNK theo cac tieu ehudn sau: 1. Tim thdy vi khudn trong dich khdp. gii. 2. X6t nghiem tl bao dich khdp gii chdn doan nhiem Idiudn edp tinh. 3. Xet nghi?m giai phau benh mang hoat dich(MHD) khdp gdi chdn doan nhiem khudn cap tinh. Chdn doan xac dinh khi cd tieu chuan 1 ho$c cd tieu ehudn 2 va 3. Doi vdi BN hdi ciiu phai cd benh an ghi ch6p ddy dii.. • Tiiu chuin logi trie: BN viem khdp gdi khdng do nhiem khudn edp tinh hoac khdng cd chi dinh phau thuat npi soi khdp. - BN cd benh an ghi chep khdng ddy dii. 2.2 Phuotig phap nghien cuu: Sur dung phuang phap nghien ciiu tiln ciiu ket hgp hdi cuu, md ta cdt ngang. Cac thdng tin dugc thu thap theo mdt mlu benh an thing nhdt. Danh gia hinh anh dai thi ben trong khdp goi, phan loai theo tieu ehudn Gachter chia ra 4 giai doan ndi soi(GDNS) cua viem khdp gdi nhilm khudn [9]: Giai doan I: Dich due va mang boat dich khdp xung huyit Giai doan II: Dich mil vdi nhieu te bao. Viem mang boat dich khdp nghiem trpng, lang dpng fibrin. Giai doan III: Dac trung bdi day mang ho?it dich khdp va tao v^ch chia khdp gii ra thanh cac khoang rieng re (dudi ndi soi trdng nhu bpt bl, dac biet d khpang tren xuomg banh che). Giai doan IV: Cac mang mau (pannus) tiln triin tham nhilm vao sun, cd the hiiy ho^i sun. 2.3. Ky thuat npi soi khdp goi Dugc tiln hanh tai phdng ndi soi khoa Tham dd chiic nang bfnh vi?n B^tch Mai. Sii dung may ndi soi khdp Ing ciing ciia cdng ty 01ympus( Nhat Ban) vdi Ing npi soi cd gdc nghieng 30" va 70 BN dugc tiem khang sinh du phdng trudc ndi soi khoang 6 gid. + Tiln hanh thii thuat: Sat triing tai cho, trai sang vd khudn vimg khdp gii dugc tiln hanh ndi soi. Gay te tai cho bdng hon hgp Lidocain 1% va Adrenalin l%o. Dudng vao: rach da vimg mat trudc khdp gdi cdn ndi soi khoang 0,5 - 0,6cm d vi 77. CHUYEN PE: CO XUONG K H O P - NHOfNG TIEN BO TRONG CHAN POAN VA tntu iKi. tri dudng trudc ngoai va trudc trong xuang banh che. Ddu soi thudng dugc dua vao dudng trudc ngoai, trocar dugc dua vao dudng trudc trong. Sau khi quan sat va danh gid ddy dii cac tin thuang trong I khdp, tiln haiih cdt. loc, lam sach cac to churc ho?i tur variiaIdidp vdi 3 - 5 lit nudc mudi sinh ly(Nacl 996o) trudc khi kit thiic thu thuat. 2.4 Xu ly kit qua nghien ciru Cac sd lieu dugc xu ly bdng thu§t toan thdng ke su dvmg phdn mIm SPSS 15.0.. I I I . KET QUA NGHIEN CUU VA BAN LUAN 3.1. Cac dac diem chung cua nhdm nghien cuu:. Bang 3.1. Cac dac diem chung cua nhdm nghien ciiu: Cac dac diem Gidi Ndi cu' trii Vj tri khdp gdi viem Tien sif viem khdp gdi Tien siir tiem khdp Tudi (nam). Nam Nij" Ndng thdn Thanh phd Phai Trai Cd Khdng Cd Khdng Trung binh ± dp lech Min - Max. S6BN (n=30) 18 12 23 7 15 15 25 5 19 11. % 60 40 76,7 23,3 50 50 83,3 16,7 63,3 36,7 47,9 ± 14,9 13 - 81. P >0,05 <0,05 >0,05 <0,05 <0,05. : p khi so sdnh giita so BN cua nhom ii benh < 2 tudn vdi nhom >2 tudn. Nhdm nghien cxm gdm 30 BN VKGNK di6u tri ndi tni va dugc ndi soi khdp gdi tir thang 1 nam 2006 den thang 9 nam 2009 cd tuli trung binh la 47,9 ± 14,9, nhd nhdt la 13 va ldn nhdt la 81 tudi. Nhdm tudi BN cua chiing tdi ciing tuang tu nhu d nghien ciiu cua Nguyen Mai Hdng [3], Bussiere [7]. Khdng cd sir khac biet vl gidi tinh va vi tri khdp gdi bi nhiem khudn (p>0,05). Vl nod cu tni, BN sdng d ndng thdn chilm phdn ldn. 78. (76,7%) so vdi d thanh phd (23,3%)(p<0,0fi). Phdn ldn sl BN nay cd tiln sir viem khdp goi tir trudc dd (83,3%) va cd dugc tiem khdp ho^ lam cac thii thuat d khdp(dan luu dich, chpc hiit dich,...) (63,3%). Su khac biet giiia nhdm cd tiln sir viem khdp vdi nhdm khdng cd viem khdp, gifta nhdm cd tiln sur tiSm khdp vdi nhdm khdng cd tiem khdp la cd y nghia thing ke (p<0,05).. Ndi KHOA - S 6 4/2009. 3.2. Dac diem hinh anh n^i soi khdp gii d BN VKGNK: Bang 3.2. Dac diim hinh anh ndi soi khdp gii d BN VKGNK: Dac diem. Khdng. Nhe. yifa. n. %. n. TSng sinh hinh Idng. 1. 3,3. 21. Tanq sinh mach mau. 1. Xunq huyet MHD. 0. 3,3 0. 6 4. 13,3. 6 11 14. l i n g dpng fibrin. 0. 0. 0. 0. 5. % 70 20. v l dac diem hinh anh hdi soi Ididp gdi cua BN VKGNK, hdu hit cac BN trong nhdm nghien ciiu ciia chiing tdi cd cac tin thuang CO ban nhu tang sinh hinh ldng, tang sinh mach mau MHD (96,7%), xung huyit MHD (100%), ldng dpng fibrin (100%). Trong dd, tin thuang tang sinh hinh long phdn ldn gap d miic dp nhe (70%), miic dp vira va n^ing gap d 26,7%. Tin thuang tang sinh m^ch mau chu ylu gap d miic dp vira va n^g (tuomg ling la 36,7 va 40%) chilm 76,7%. Miic dp xung huyit MHD ciing chu yeu g^p d miic vira va nang chiem 86,7%.. n. Nang. % 20 36,7 46,7 16,7. Tdng. n 2 12. % 6,7 40. n 30 30. % 100 100. 12 25. 40 83,3. 30 30. 100 100. Cdn tinh trang lang dpng fibrin trong nhdm nghien ciiu cua chiing tdi chi gap d miic dp vira va nang, trong dd chu yeu la mire dp nang (83,3%). So vdi nghien cim cua Nguyin Mai Hdng [3] thi tdn thuang tren ndi soi cua nhdm BN trong nghien ciiu cua chiing tdi cd ty le gap cao ban va mire dp nghiem trpng ban. Tuy nhien, chiing tdi khdng gap cac tdn thuang xuong va sun khdp. Diiu nay cd the la vi nhung BN cd tdn thuang xuong, sun khdp la d GDNS IV theo phan loai cua Gachter va da dugc diiu tri can thiep bdng ngoai khoa.. 3.3. Moi lien quan giira thdi gian mdc benh vdi cac GDNS: Bang 3.3. Mii tuang quan giiia thdi gian mdc benh vdi cac GDNS: Giai doan ndi soi II. Trieu chiihg. Thdi gian ii benh tri/dc khi vao vien (ngay). Thdi gian ndi tni tru'dc NSK(ngay). Tong. 1 4 0 5 10. 10 40 0 50 100. 1 3 '2 9 15. 6,7 20 13,3 60 100. <7 >7 Tong. 2 8 10. 20 80 100. 5 10 15. 33,3 66,7 100. 1-7 8-14 15-21 >21. Tong. III 0 1 2 2 5. 0 20 40 40 100. n 2 8 4 16 30. 6,7 26,7 13,3 53,3 100. <0,05. 2 3 5. 40 60 100. 9 21 30. 30 70 100. <0,05*. *pkhi so sdnh giUa tdng s6 BN cua nhom u binh < 2 tudn vdi nhdm >2 tudn. ^ \khi so sdnh giUa tdng s6 BN cua nhom diiu tri ngi tru truac NSK < I tuan vai nhom >I tudn 79. CHUYEN oi: CO Xl/ONG K H O P - NHUTNG TIEN BO TRONG CHAN DOAN VA tJIfcUiK!. Trong nhdm BN nghien ciiu cua chiing tdi, sd BN VKGNK den sdm trong vdng 1 tuan gap rat it(6,7%). BN den sdm nhat trong nghien ciiu nay la sau 3 ngay va mupn nhat la sau 4 tuan. Hau het BN cua chiing tdi (93,3%) cd thdi gian u benh trudc khi vao vien >1 tuan. 66,6% BN den vdi chiing tdi sau 2 tudn. CJ tat ca cac GDNS, sd BN den mupn sau 1 tuan deu chiem phan ldn. Trong thdi gian do, cac BN da dugc dieu tri tai cac tuyen trudc. Phan ldn BN da dugc dieu tri bang khang sinh, chdng viem tham chi la corticoid, mpt sd da dugc chpc hiit dich, dan luu dich, ... Nhu vay, viec dieu tri d cac tuyen trudc da gdp phan han che su tien trien cua cac giai doan viem khdp. Nhung dieu do ciing di ddi vdi viec chan doan xac dinh tinh trang nhiem khuan khdp tai thdi diem nay gap nhieu khd khan, chi cd 30% BN dugc tien hanh ndi soi khdp trong vdng 1 tuan cdn phan ldn dugc can thiep muon han (70%), su khac biet nay cd y nghia thdng ke vdi p<0,05. Va nlu BN khong dugc lam NSK dl chan doan xac dinh, danh gia giai doan, tinh trang viem khdp thi se rat khd de dieu tri va tien lugng cho BN[10].. Stutz(2000) nghien ciiu 78 trudng hgp viem khdp nhiem khudn trong dd cd 62 trudng hgp la khdp gdi, nhan thdy 28,2% BN d giai doan I, 56,4% d giai doan II, 15,4% d giai doan III, khdng cd BN d giai doan IV[9]. Vispo(2002) nghien ciiu tren 88 trudng hgp viem khdp nhiem khuan, trong dd cd 78 trudng hgp la khdp gdi, nhan thay hau het benh nhan dugc can thiep ndi soi khdp trong vdng tir 2 den 14 ngay ke tir khi xuat hien trieu chiing, trung binh la 13 ngay. 50% so BN dugc can thiep ndi soi khdp trong tuan ddu tien cua benh, 23% trong tuan thir hai va 25% trong tuan thii ba. Trudng hgp can thiep mupn nhat la sau 3 thang. Tac gia nhan thay cd mdi tuang quan giiia thdi gian can thiep npi soi khdp vdi giai doan tdn thuang tren npi soi theo hudng cang de lau cang ton thuang nang [10]. Balabaud nghien ciiu tren 40 BN d Phap nam 2007, nhan thay thdi gian trung binh kl tir khi cd trieu chiing din khi dugc can thiep npi soi khdp la 15 ngay, dao dpng tir 1 den 59 ngay va cd 35% BN dugc dieu tri d cac benh vien khac trudc dd[6].. 3.4. Moi lien quan giii'a mot so xet nghiem bieu hien viem trong mau ngoai vi vol cac GDNS d BN VKGNK: Bang 3.4. Moi lien quan giira mpt sd xet nghiem bieu hien viem trong mau ngoai vi vdi cac GDNS d BN VKGNK: Giai doan ndi soi Ca nhdm. Xet nghiem. Bach cau (G/l) Mau lang gid dau (mm) Mau lang gid thu" 2 (mm) CRP (mg/dl). 80. I. II. III. 8,6 ± 0,6 n=10 65,9 ± 27,1 n=10 89,8 ± 17,2 n=10 6,2 ± 4,1 n=7. 11,3 ± 1,3 n=15 94,3 ± 22,7 n=15 104,8 ± 18,7 n=15 6,8 ± 5,3 n=10. 13,5 ± 4,9 n=5 91,4 ± 17,5 n=5 113,6 ± 17,3 n=5 12 ± 2,3 n=4. 10,8 ± 5,7 n=30 84,4 ± 26,4 n=30 101,3 ± 19,5 n=30 7,6 ± 4,8 n=21. P. <0,05 <0,05 <0,05 >0,05. NOI KHOA - S6 4/2009. ^ v l cac chi sd xet nghiem p h ^ anh tinh trang viem frong mau ngoai vi, chimg tdi nhan thay cd svr khac biet cd y nghia thing ke(p<0,05) giira cac GDNS d chi sl bach cdu, mau ldng d gid thii iihat v^ gid thii hai. Theo dd, BN VKGNK cd GDNS mudn ban thi cd chi sd bach cdu, mau lang gid thu nhat va gid thii hai trung binh cao ban. Tuy nhien ddi vdi chi sl CRP, khdng cd su khac biet giura cac GDNS(p>0,05). Diiu nay cd thi la vi sd luong BN chua dii ldn dl phan anh su khac biet, hoac cac BN VKGNK trudc khi vao diiu tri d khoa Co Xuong Khdp, benh vien Bach Mai da dugc diiu tri d cac tuyln trudc. 201. S > u. 10. u o T3. a o. Z. -10 N. 10. Giai doan viem khop theo Gachter Biiu do 3.1. Thay ddi cua ndng dp CRP trong mau ngoai vi theo cac GDNS Qua biiu dd 3.1, ta nhan thdy theo biiu I V KET LUAN: do hOp, chi sd CRP cd xu hudng tang len Qua nghien ciiu ndi soi khdp gii 30 BN tuong ling vdi giai doan NSK. Tuy nhien, VKGNK trong nghien ciiu nay, chiing tdi miic dp dao dpng ciia day sl lieu cung cdn nhan thdy: nhieu cho nen can khao sat vdi sd lugng BN 1, Ve hinh anh ndi soi khdp cua BN ldn hon de khang dinh dugc mdi lien quan VKGNK: Gap nhieu cac tdn thuang tang sinh hinh ldng(96,7%) vdi 26,7% tang sinh nay. Balabaud(2007) trong nghien ciiu cua vira va nang. 96,7% BN cd tang sinh m^ch minh nhgn thdy bach cdu trong mau ngoai mau MHD, miic dp nang chilm 40%. 100% bien tnmg binh la 10,8 ± 3 G/l, mau ldng gid BN cd xung huyet MHD khdp. Tinh trang ddu frung binh 107 ± 23mm va CRP trung ldng dpng fibrin gap d tat ca cac BN trong dd binh la 16,5 ± 10,1 mg/dl[6]. Bussiere(Phap, 83,3% la d miic dp nang. Theo phan la?i ciia 1997) trong nghien ciiu cua minh nhan thay Gachter, GDNS I gap d 33,3%, 50% BN d b^ch cdu trong mau ngoai bien trung binh giai doan II va 16,7% d giai doan III, khdng 11,7G/1, mau ldng gid thii nhdt trung binh la cd BN d GDNS IV 2, 6 tdt ca cac GDNS, ty le BN din sdm 73mm(17-124), CRP tnmg binh la 19,3 (1,2 trong vdng 1 tudn diu thdp(0-10%). Ty 1? BN -'42,0)mg/dl[7]. dugc lam ndi soi khdp Uong vdng 1 tudn kl tir khi vao vien d cac GDNS tir 20% din 81. CHUYEN P i : CO Xl/ONG K H O P - NHQTNG TIEN BO TRONe CHAN O O A N V A tiicu iKj. 33,3%, cdn lai phan Ign BN d i u dugc can thiep sau 1 tudn. Cac chi sd bach cdu trong mau ngoai vi, mau lang d gid thii nhdt va gid thii hai liic vao vien cua BN cd gia tri trung binh tang ddn tuang ung vdi su tang len cua GDNS, su khac biet giiia cac GDNS la cd y nghia thong ke vdi p<0,05. Chi sd CRP trung binh liic vao vien cd xu hudng tang len theo sir gia tang GDNS tren biiu dd hop, su khac biet khdng cd y nghia thong ke (p>0,05).. 5.. 6.. 7.. TAI LIEU THAM KHAO: 1. Tran Ngpc An (1999), "Viem khdp nhilm khuan (khong do lao)", Benh thdp khdp, Nha xuat ban Y hoc, 172-183. 2. Tran Ngpc An, Nguyen Thi Ngoc Lan (2004), "Dieu trj cac benh viem xuang khdp nhilm khudn", Dieu tri hoc Npi khoa, tap I, Nha xuat ban Y hoc, 237 - 240. 3. Tran Mai Hong, Vu Thi Thanh Thuy (2006), "Ung dung npi soi khdp trong dieu tri viem khdp goi do nhilm khuan", Yhoc thirc hdnh, sl 7, 26 - 29. 4. Nguyen Vinh Ngpc, Nguyen Thi Ngpc Lan (2Q07), "Nghien ciiu dac diim lam sang, can lam sang va diiu tri viem khdp nhilm khudn tai khoa Ca Xuomg Khdp - Benh vien B^ch. 82. 8. 9.. 10.. Mai", Y hgc ldm sdng, sd dac san 9-2007, 133 - 1 3 7 . Atkins BL, Bowler ICJW(\99^), "The diagnosis of large joint sepsis",^ Joumal of Hospital Infection, 40: 263 - 274. Balabaud L, Gaudias J, Boeri C, Jenny JY, Kehr P (2007), "Results of treatment of septic knee arthritis: a retrospective series of 40 cases". Knee Surgery, Sports Traumatol, Arthroscopy, 15(4): 387-392. Bussiere F, BeauHls P (1999), "Role of arthroscopv in the treatment of pvogenic arthritis of the knee in adults. Report of 16 cases". Rev Chir Orthop Reparatrice Appar Mot. 85(8): 803 10. Smith MJ (1986), "Arthroscopic treatment of the septic knee". Arthroscopy, 2(1): 30 - 4. Stutz G, Kuster MS, Kleinstuck F, Gachter A (2000), "Arthroscopic management of septic arthritis: stages of infection and results". Knee Surgery, Sports Traumatology, Arthroscopy, 8: 270 - 274. Vispo Seara JL, Barthel T, Schmitz H, Eulert J (2002), "Arthroscopic treatment of septic joints: prognostic factors". Arch Orthop Trauma Surg, 122: 204 - 211..