TAP CHI NGHIEN COU Y HOC DIEU TRI BIEN DANG KHIPitU VE0 VAO TRONG VO'l KY THUAT DUC XU'O'NG SU'A TRUC CO s Cr DUNG DINH VI GOC BANG KIM KIRCHNER TrAn Trung Dung Truong Dai Hoc Y Ha Ndi Nghien cuu nham m6 to ton thvang bien dpng va xoay cua khuyu benh nhan bien dpng khuyu vao va danh gia ket qua diet, tri khuyu vao vai kSi thuat duc xu'ang sera tryc co set dung dinh vi gOc bang kim Kirchner Nghien ciru tien cure m6 to 24 benh nhan khuyu vao Cac benh nhan ducvc pilau thuat sera chCra khuyu vai ky thuat duc xuong sera truc co dinh vi gOc bang kim Kirchner Kat qua nghien ciru cho thay goc 1/00 trung binh la 24,8 ± 5.6 G6c xoay trung binh la 21.4 ± 6,7 Kat qua sau m6 theo phan lopi cua 1ppolito la t6t 83.4% kha 8,3% va kern 8.3% Phau thuat arc xtrang sera tryc veyi kk" thuat dinh gOc vi bang kim Kirchner cho kat qua t6t Keywords: vgo khuyu vao trong, dyc )(in:mg sin tryc I DAT VAN DE Gay tren I6i cau xtyang canh tay tre em chiern 50% gay vung khuyu tre em Dieu tri gay tren I6i caw Arang canh tay chu yeu Ia dieu tri bao ton, rat it truOng hop phai can thiep phau thuat Du dieu tri bao ton hay phau thuat thi di chirng khuyu (vao hoac ngobi) van gap vai tan suat kha Ian (kr 40 50%) theo tac gia [1; 2; 3], chu yeu la bien dang khuyu vao Bien dang khuyu anh hithng khong chi tham m9 ma phan den chirc nang khOp khuyu, nhat la nhu cau sCra chCra ben dang ye mat tham m9 tang cao Bien dang khuyu kh6ng chi don thuan la ben dang ma ca ben dang xoay cua khoi 16i cau, Nen dang xoay de bi b6 qua va khO xac dinh chinh xac vi CO st,r bu trio cua khOp vai va hai khdep quay tru tren va dual NhCrng danh gia Dia chi lien he: Tran Trung DOng, BO mOn Ngopi, tru&ng Doi hoc Y Ha NOi Email: dungbacsy@dungbacsy.com Ngay nhan: 23/3/2014 Ngay &pc chap thuan: 26/06/2014 TCNCYH 88 (3) - 2014 tren CT 3D cua cac tac gia cho thay gOc xoay khoang 20 d6 [1] Dieu tri khuyu vao chi] yeu la phau thuat duc xirang sCra truc CO hai ky thuat duc xu'ong sCra truc chinh la: k9 thuat m& (open wedge technique) va k9 thuat dOng (close wedge technique) ten thkrc to lam sang, doi vai khuyu vao trong, chu yeu six dung k9 thuat dOng Khi thgrc hien phau thuat duc xuarig sCra truc, ben canh khO khan chinh la dinh vi mirc cat xtyang de clam bao tha'ng two thi siva chCra xoay cua khoi 16i cau kha quan vi new kh6ng sCra duvc xoay thi khong dam bao yeu to tham m9 Ca hai kho khan deu lien quan mat thiet den van de luong gia mirc [Dien dang Lam CO the krong gia mirc dO ben dang de co the thu'c hien cat xuang va sCra truc dat hieu qua chi' kh6ng phai dinh tinh di.ra ten kinh nghiem cua phau thuat vien? Tai benh vien Dai Hoc Y Ha NOi va benh vier' Viet Dire, chi:mg t6i da sir dung phtyang phap dinh vi truc bang kim Kirchner de danh gia mirc dO a bien dang va xoay trong, tir (JO co 61 TAP CHI NGHIEN CU'U Y HQC the thu'c hien cat xiyang va sCra truc chinh xac theo tinh toan Nghien cCru danh gia ket qua pheu thuat dieu tri khu9u vao vai k9 - OuVng rach da tren loi cau ngobi nrang canh tay va doc theo truc xtyang canh tay - Phu tich b6c 16 du quan sat mat ten, thuat mO duc xtrang sCra truc cai tier) nhem mat duVi cua khoi 16i cau, mat truVc va sau muc tieu: cua 1/3 thrai than xiyang canh tay de dam Mo to ton thtyang !Dien clang va xoay cua khu9u a benh nhan !Dien Bang khu9u vao Danh gia ket qua dieu tri khu9u vao vai k9 thuat duc xuang sCra truc CO six dung dinh vi goc bang kim Kirchner II DOI TUVNG VA PHLYO'NG PHAP bao dinh vi chinh xac - Dinh vi kim Kirchner thCr nhat vuong gOc vai truc cua xtyang canh tay dt,ra tren cac mac mat truac, mat sau cua xtycing va b6 ngoai cua xtyang canh tay, dam bao vi tri kim cach dien khap 10 cm, cach [16 khu9u cm, nOrn tren mat phang dirng ngang giCra xtyang canh tay - Dinh vi kim Kirchner thir hai a vi tri loi cau 1.061 tuvng ngoai, song song vai mat pheng trtrO'c va sau 24 benh nhan duvc chen doan khu9u cua khoi loi cau, vuong goc vai truc cua cOng vac) duvc ph5u thuat tai benh vien Viet tay va di tCy 161 cau ngoai vao loi cau Dirc va benh vien Dai Hoc Y Ha NOi vai k9 xtyang canh tay thuat mO cai tien co sir dung dinh vi kim - Quy chieu vi tri hai kim len mat phang Kirchner tip nam 2009 den 2012 (ban quyen dirng ngang, goc nghieng giCra hai kim chinh tac gia so 282/2014/QTG) la gOc trong, (hinh 1) Phu'o'ng phap: m6 to tien cCru, theo d6i doc Cac chi heti nghien art' - Them kharn lam sang danh gia dO trong, bier' dO van dOng cua khOlp khu9u - Do dac cac g6c nghieng cua truc canh tay va truc cOng tay (goc canh tay tru) ten phim X quang de xac dinh tinh tang trirac va sau mO - Xac dinh goc va xoay cua khu9u ma sau da dinh vi kim Kirchner Ky thuht phhu thuht dyc xu'o'ng sCra truc chi tier) co sir dyng dinh vi kim Kirchner - Gay me toan than hoac dam r6i than kinh Milt Hinh Xac dinh goo diva trail mat phang domg ngang - Quy chieu vi tri hai kim len mat phang canh tay - Garo hai hoec Esmach 1/3 tren canh tay nem ngang, gOc nghieng giCra hai kim chinh la sau don mau goc xoay cua khu9u, (hinh 2) 62 TCNCYH 88 (3) - 2014 TAP CHI NGHIEN CO'U Y HOC COc xoay Kink I &Eng ngang va tao vai gOc khoang to den 10 TO, de mo, kh&p khu9u ngoai Khi da dam bao yeu c6u tren, c6 dinh bang Kim hoac kim Kirchner cheo qua gay hoac vit - Cam mau k9, dat clan - nho BO bOt canh c6ng ban tay rach doc tu' the du6i khu9u tusan, sau dO thay nep bOt tkr the gap khu9u Theo bOt sau tuen va tap phuc Xoay hoi chirc neng Hinh Xac dinh g6c xoay diva tren mat phang nam ngang Danh gia ket qua - Van de lien vet thu'ang - Dinh vi lat cat Apang thCr nhat la diro'ng song song vOl kim Kirchner thir hai, a phia ten dinh cua ho khu9u - Van de lien xtyang - Danh gia ket qua xa dkra tren yeu to: bien dO van dOng va truc cua ca'ng tay dkra - Dinh vi let cat xirceng thCE hai la dififYng tren phan loai cua Ippolito chia ba mirc dO: song song vai kim Kirchner thCr nhat dam bao Tot, kha va kern Trong d6 tot: Nen dO van cho hai let cat gap & ba cua dOng khuYu binh thirOng, khuYu th5ng truc; >arcing canh tay kha la Nen dO van dOng binh thubmg, - C5t xiyang theo lat cat da dinh vi nhe hoac bien dO han the nhe nhung - Ap sat hai dien cat nrang dam bao yeu khu9u th5ng truc; kern la co han the bien dO van dOng cau hai kim dinh vi nam tren cOng mat ph5ng III KET QUA vow Tir - 10 tan Nam 71% Tn 11 - 15 Nir Tren 15 tuoi Blau d6 Ty la nam nip Blau Tuoi benh nhan can thiap phiu thuat Da s6 benh nhan &roc can thiep phau thuat giai doan 11 den 15 tuoi, tuoi trung binh cua benh nhan la 10.5 ± 5,4 tuoi TCNCYH 88 (3) - 2014 63 TAP CHI NGHIEN CCrU Y HQC 11.7% KhOti phai S8.3% Klittjw trai Bi6u d6 3: Tay bi khuyu Tinh tang khuyu a tay trai gap nhieu hart tay phai Bang GOc cOa khuyu n GOc Ti)' 20 - 30 dO 18 75% Tren 30 dO 25% 24,8 ± 5,6 Trung binh Goc trung binh la 24,8 ± 5,6 75% nam khoang tir 20 den 30 d6 Bang G6c xoay ctia khuyu GOc xoay n Ti)' 15 - 20 dO 13 54,2% Tren 20 dO 11 45,8% Trung binh 21,4 ± 6,7 Goc xoay trung binh cua khuj/u la 21,4 ± 6,7 KM qua kiern soat m6, 100% cac truVng hap sCra chCra duvc di lach xoay Danh gia ket qua On khOng co tru'Ong hop nao nhrem trung, lien seo thi claw sau ph6u that thuan loi Goo ngoai danh gia mO tir den 10 d6, trung binh la 6,5 dO KhOng co !Dien chirng liat than kinh sau phAu thuat Danh gia ket qua v61 thdi gian theo doi trung binh 6,5 thang chung t6i thay khOng co truteng hap nao han the bien dO van dOng khujru 64 TCNCYH 88 (3) - 2014 TAP CHI NGHIEN ciru Y HOC Bang GOc canh tay try sau phAu thuat G6c ngoai khuyu n % 0% TO, - dO 21 87,5% Tren dO 12,5 < dO Trung binh 3,4 ± 2,6 Danh gia kat qua sau mO vai thai gian theo dOi trung binh 6,5 thang, khOng co twang hap nao tai phat G6c ngoai trung binh la 3,4 ± 2,6, phi) hap vai gOc ngobi sinh ly cua cac benh nhan Bang Danh gia ket qua xa theo Ippolito K6t qua n T6t 20 83,4% Kha 8,3% Kern 8,3% Tong 24 100% Kat qua tot va kha chiem 91,7% IV BAN LUAN Ty le nam cao han nix (71% so vai 29%) ICic toc d6 phat trien xt.rang cham lei Tuy nghien cCru cua chCing tOi cOng phO hap vai nhan dinh cua da so cac tac gia khac ntar nhien, khuyu la ton thu,ang mang yeu to them m9 nhieu han la chirc nang nen cua Isa Sawaqued nam 59%, nu' 41% [2], Le nhirng trutyng hap nhieu, cac tac gia Thanh San nam 60% nO, 40% [3] cang khuyen cao nen mO sam vi tre dang Tu6i trung binh nghien ciru cua chimg toi la 10,5 ± 5,4 tuOi, ket qua cao tuOi di hoc nen de bi anh hu'ang tam ly cac ban treu choc [2; 3; 6] han nghien CCYU cua mot so tac gia Le Thanh San, Issa Sawaqed [2; 3] va khac nhu, Mohammad Musa [4] vai tuOi trung binh 7,05 hay NgO HCru Hanh 7,1 [5] Tu6i nhieu tac gia khac deu co ket qua cho they ton thu,ang gap a tay trai nhieu han tay phai va benh nhi can thiep co lien quan kha chat cho rang tay trai la tay khOng thuan nen the vai nguy ca tai phat via dO tuOi nga, kha nang chong dO vung ve han nen de xuang can dang phat then Vi vay, mot so ton thiyang Ket qua nghien Cl:PU cua tac gia co de xuat nen mO khuyu muon, chung t6i cung phO hap vai nhan dinh tren vai tren 10 tuOi de giam nguy co tai phat tY le ton thirang tay trai la 58,3% TCNCYH 88 (3) - 2014 65 TAP CHI NGHIEN COU Y HOC G6c trung binh trtyac mO cua cac the kiem soat chinh xac duvc Diem lai y van benh nhen la 24,8 ± 5,6, le nhCrng thkrang tem ye cac phkrang phap ph5u thuat siva china veo nhieu Gia tri g6c dm chung toi cao khu9u thi they reng, cac phu,ang phap ph5u han die cac tac gia khac nhu' Beslikas, thuat chu yeu nhec den sira china Ippolito, Miura [6; 7; 8] Tinh trang nang ve han nCra la kh6ng c6 kha nang dinh luvng cua khu9u kh6ng chi anh hu,c'yng den them m9 chinh xac mirc cet xu,ang vi vay pheu thuat ma Om su, virng chec cua khu9u cOng dkra nhieu kinh nghiem cua ph5u thuat nhu, tang nguy co' gay xtyang cher) thkrang vien han Phiyang phap cua chCing t6i cho khu9u Tuy nhien, tre dang a tuOi phat trien phep dinh luvng ca g6c NM() va g6c xoay nen xu the tai phat cao vi vay da so cac cua khu9u va cho phep kiem tra tru'c tiep tac gia thong nhet reng chi nen can thiep m6 mirc d6 siYa china ca hai gOc nhCing twang hap khu9u nang va nen tri dO D6 le u'u diem vtivt trOi ve cho phep cac hoen muOn sau 10 tuOi le tot nhet [3; 6] ph5u thuat vien tre cOng co the thkrc hien Luvng•gia gOc xoay cua khu9u chinh xac va hieu qua ph5u thuat nhCrng triyang hap khu9u kha khO khan Ket qua chung danh gia theo Ippolito tot la Bien clang xoay kh6 danh gia ca tren 83,4%, kha 8,3% va kem 8,3% Nhet la ket lam sang va Xquang ye mat lam sang, qua kem cua chOng t6i it han hen so vai khap khu9u du,gc bu trO, !DOI khap vai Ippolito (45,8%) [6] hay Le Thanh Sun phim Xquang thi chi danh gia &lac chieu (45,1%) [3], dieu cho they sir dung dinh Naito A va cOng sty [9] de de xuet danh gia Scr vi giup pheu thuat duvc de dang va chinh xoay cua khu9u beng CT 3D, Row [1] de xac han xuet gOc xoay beng sieu am, Tuy nhien, nhirng phkrang phap cOng kh6ng duvc sir V KET LUAN dung rOng rai Mahaisavasiya da sir dung m5u Qua nghien CCPU tren 24 trkrang hap cet xuang ph5u thuat de danh gia !Dien khu9u dirac ph5u thuat siva truc vai dang xoay va chi reng g6c xoay trung sir dung phkrang phap dinh vi beng kim binh le 27 dO [10] SO, dung phirang phap dinh Kirchner chung tOi they reng: vi beng kim Kirchner cua chung tOi chi reng goc xoay trung binh cac trkro'ng G6c trung binh le 24,8 ± 5,6 G6c xoay cua khu9u trung binh la 21,4 ± 6,7 hop khu9u le 21,4 ± 6,7 dO Ket qua dieu tri sau mO 100% siva Danh gia tru'c tiep mO, 100% cac trutrng china dirgc goc xoay ve vai hap gOc xoay cua khu9u du'cc chinh g6c ngoai sau m6 trung binh le 3,4 ± 2,6 siva hoan toan nhien viec luvng gia sau ph5u thuat ye lam sang va X quang thi khOng danh gia mot cach dinh Ikrang mCrc xoay cua khu9u Day la han the cua Ket qua chung theo phan loai Ippolito le 83,4% tot, 8,3% kha va 8.3% ken" TAI LIEU THAM KHAO phkrang phap vi chi danh gia duvc Ito N, Eto M, Maeda K (1995) Ultra- phAu thuat Vai skr hó tra cua dinh vi beng kim sonographic measurement of humeral torsion Kirchner, viec nen chinh siva g6c va J Shaulder Elbow Surg, 4(3), 157 - 161 gOc xoay de dang va chinh xac han, ke Issa Sawaqed (2005) Correction of Cu- ca mirc dO ngoai bao nhieu dO cOng co bitus Varus by Supracondylar Lateral Closing 66 TCNCYH 88 (3) - 2014 TAP CHI NGHIEN CIYU Y HOC Wedge Osteotomy Bahrain Medical Bulletin, humerus osteotomy in chidren, J Bone and 27(4) joint - surg, 757 - 765 Le Thanh San (2001) Danh gia ket qua Beslikas JA, Kirkas JM (1999) Pediat- lau dai dieu tri ph5u thuat khuctu vao ric orthopedic department, Avistole Univesity Luan van thac si y hoc, truang Doi hoc of the ssa lonnik, Greece Acta Orthop Beg Y He Neil 65- 71 Mohammad Musa (2010) Displaced Supracondylar Humeral Fractures In ChildrenTreatment Outcomes Following Closed Reduction And Percutaneous Pinning The Internet Journal of Orthopedic Surgery, Miura H, Tsumura H (1988) Interlocking wedge osteotomy for cubitus varus deformity Fukuoka - lgaku - Zasshi Apr, 40(8), 91 - 94 Naito A, Nishio K Y (1990) Internal 1531 - 2968 Ng6 Flivu Hanh (2001) Nghien ciru ket qua phuc h6i chirc nang sau dieu tri gay tren rotation angle measurement of the elbow with loi c'eu xtyryng canh tay tre em Luan van thac pon — igaku — Hoshasen, 50(12), 661 - 1613 si y khoa, tareyng Doi hoc Y Ha Ni three dimensional reformetted C.T image Nip- 10 Mahaisavariya B, Laupaharakasem Ippolito E, Meneta MR (1990) Post — Traumatic cubitus varus Long term following — up of corretion Supracondylar W (1994) Rotation deformity of the distal in cubitus varus J Med Assoc Thais jun 77(1), 19 - 24 Summary CLOSE WEDGE CORRECTIVE OSTEOTOMY TECHNIQUE WITH K - WIRE ORIENTATION FOR CUBITUS VARUS TREATMENT The objectives of the study were to describe varus angle and internal rotational angle in cubitus varus patients and to evaluate the result of close wedge corrective osteotomy with K - wire orientation for cubitus varus treatment Patients and method: Observational prospective study was carried on 24 cubitus varus patients All patients were treated surgically with close wedge corrective osteotomy technique with K - wires orientation The results showed that the average varus angle is 24.8 ± 5.6; internal rotational angle is 21.4 ± 6.7 Post operative results according to Ippolito classification for Good, Moderate,and Bad 8.3% are 83.4%, 8.3% and 8.3% respectively In conclusion, close wedge corrective osteotomy technique with K-wire orientation for cubitus varus treatment give good results Keywords: cubitus varus, corrective osteotomy TCNCYH 88 (3) - 2014 67 ... dung dinh vi kim - Quy chieu vi tri hai kim len mat phang Kirchner tip nam 2009 den 2012 (ban quyen dirng ngang, goc nghieng giCra hai kim chinh tac gia so 282/2014/QTG) la gOc trong, (hinh 1)... k9 thuat duc xuang sCra truc CO six dung dinh vi goc bang kim Kirchner II DOI TUVNG VA PHLYO'NG PHAP bao dinh vi chinh xac - Dinh vi kim Kirchner thCr nhat vuong gOc vai truc cua xtyang canh tay... - Xac dinh goc va xoay cua khu9u ma sau da dinh vi kim Kirchner Ky thuht phhu thuht dyc xu'o'ng sCra truc chi tier) co sir dyng dinh vi kim Kirchner - Gay me toan than hoac dam r6i than kinh