Nhận xét kết quả điều trị thoái hóa khớp gối bằng phẫu thuật nội soi tạo tổn thương dưới sụn

TuOi mac Wit trung
sieu am, FNA, STTT, MBH
binh la 45,3 ± 13,7 tu6i. Phan Iden gap & giai nu', tY le
nidnam la 2/1. Ly do den kham chi yeu tkr phat hien
khOi sung %king co 53,3%. Kham lam sang phat hien
&roc hpch co chiem 26,7%, tap trung chu yeu la
hpch nhom III, IV chiem 87,5% vai cac tinh chat:
100% mat dO chac, 100% cac hpch c6 khong c6 bieu
hien dau, 87,5% ranh giai khong CO, 87,5% di dOng
hpn che. Doi chieu hpch tren lam sang va ket qua mO
berth hoc hach co: DO nhpy cao nhat b nhom III kham
phat hien tren lam sang, chiem tY le 50%, nhom IV
46,7%, nhom V 40%. DOi chieu vi tri hach di can vai
khOi u tuyen Op: PhAn Ian hpch di can cung ben vai
khOi u tuyen giap chiem 66,1%. DOi chieu giCra sieu
am hach co va ket qua ma berth hoc hpch co: Sieu
am có dO nhpy 100% vai hach di can nhom I, dO
nhpy 85,7% vai hach di can nhom III, nhom IV la
80%. 06i chieu hach co phat hien trong khi phAu
thuat va ma b'enh hoc hpch co: Phu thuat nao vet
hach co nhom I có dO nhpy cao nhAt chiem 100%,
hpch nhom II, Ill, IV dO nhay twang dOi giOng nhau
Ian luvt la 83,3%; 82,3; 83,3%. DO nhay cua nao vet
hpch co vai nhom VI chiem 65,2%, thap hurl a nhom
V la 40%.
TAI LIEU THAM KHAO
1. Delisle M. J, Schvartz C, Theobald S et al
(1996), Cancers of the thyroid. Value of a regional
registry on 627 patients diagnosed, treated and followed
by a multidisciplinary team, Ann Endocrinol (Paris).
57(1), 41-49.

2. Candy B va Rossi RL (1991), Sugery of Thyroid
and Parathyroid Glands, Third Edition, W.B. Saunders
Company, 14-151.

3. Nguyen BS DCrc (1999), Ung thu, tuyen giap
trang, Huong clan thuc hanh, char, doan lieu tri ung Chu,
NXB Y hoc, 135 - 149
4. Le Van Quang (2003), Vai tit dia xet nghiem to
bac hoc qua choc but bang kim nho trong chhn doan cac
buteu nhan tuyen giap, Tap chi Ngoai khoa (2), 1-7.
5. Rossi R. L, Cady B, Silverman M. L et al
(1988), Surgically incurable well-differentiated thyroid
carcinoma. Prognostic factors and results of therapy,

Arch Surg. 123(5), 569-74.
6. Pham Van Him, Le Minh Kjf, T6ng Xuan
Th6ng et al (2015), Nghien ciru dac diem di can hpch
co cua ung thu bleu mO tuyen giap the nhil tai Benh vien
Tai Mui Hong Trung wyng, Tap chi Tai MOi Hong Viet
Nam. 61(31), 5-10.
7. Nguyen Xuan Phong (2011), Nghien cOu dac
diem lam sang va mot so )(et nghiem trong ung thin bieu
me tuyen giap, Luan van thac s9 y hoc, Dai hoc Y Ha
NOi.

8. Nguyen Van Wing (2013), Danh gia ket qua
diet, tri ung Chu' Myer) giap tai Benh vien Tai MOi Hong
Trung uong va Benh vier? Bach Mai giai dopn 2007 2013, Luan van Thac s9 Y hoc, Dai hoc Y Ha NOi, Ha
NOi.

9. Nguyen Thi Bich Ngoc (2014), Nghien cOv dac
diem lam sang, can lam sang hach c6 di can cOa ung
thu' bleu m6 tuyen giap the nhu, Luan van Thac s9 y
hoc, Dpi hoc Y Ha NOi, Ha NOi.

NHA N XET KET QUA DIEU TRI THOAI HOA KHo'P GOI
BANG PHAU THUAT NOI SOI TAO TON THU'O'NG DU'O'I SUN
NGUYEN HOANG THAI', TRAN TRUNG DUNG'
NGUYEN TRAN QUANG SANG'
'Hoc vien cao hoc kh6a 23, Truang Dai hoc Y Ha N6 i
2 Troong Dai hoc Y Ha N6i
TOM TAT
Muc lieu nghien ceru: Danh gia Vet qua pheu thuOt
nOi soi (PTNS) va tao tem thuung dux"i sun dieu tri
thoai hea khop gOi (THKG) bang Chang diem VAS
(Visual Analogue Scale) va (hang diem KOOS (Knee
Injury and Osteoarthritis Outcome Score). Del tugng
va phuung phap nghien aftr: Gem 27 benh nhan
(BN) THKG de I va de II da ducc chen doan va u
trj bang ph& thuat 170i soi tai Benh vien Xanh Pen.
Tat cd cac BN da duryc kham theo doi va danh gia
de dau, bien de van Ong gOi, va SI/ hai !Ong ctia BN
sau khi ph5u thuat theo Chang diem VAS va KOOS
Chju trach nhiem: Nguyen Hoang Thai
Dia chi: Trueng Dai hoc Y Ha Nei
Email:
Ngay nhan:26/9/2016
NO)/ phan bien: 21/10/2016
Ngay duyet bai: 28/10/2016

Ngay met ban: 20/11/2016

HQ(: TIIVC HAN11 (1026)- SO 11/2016

tai cac th&i diem 1 thang, 3 (hang, 6 (hang, 9 (hang
va 11 Mang. Ket qua nghien aru: bleu het cac bent)
nhan sau mO deu CO str cal Mien re ret ye mat lam
sang Ira chat luting cuec song so vai lac truer ph5u
thuat. Thang diem KOOS (rung binh sau mO clpt
86,47 diem, VAS van deng (rung binh sau mO apt
1,78 diem. Ket luau: THKG dq II va II dieu tri bang
phgu thuat Wei soi tao then thuung dudi sun dal /a
phuung phap dieu trj cho ket qua tot, giap cai thien ro
ref cac trieu chirng sau ph5u thuat.
TO, khoa: Thodi hoa khop goi, 0o ton thuung
dutvi sun (MF = Micro fractures), Chang diem VAS,
Chang diem KOOS
SUMMARY
Objectives of the study: is to evaluate the result of
Knee Laparoscopic surgery and Knee Microfracture
surgery under treatment knee osteoarthritis by VAS
(Visual Analogue Scale) and Koos (Knee Injury and
Osteoarthritis Outcome Score). Subjects and

65


research methodologies: including 27 patients of level
I and level II who have been diagnosed with knee
osteoarthritis and treated by endoscopy surgery at

the St. Paul Hospital. All of the patients are checked,
recorded and evaluated with the pain level, knee
motion degrees, satisfaction level in accordance with
VAS and KOOS after 1 month, 3 months, 6 months, 9
months and 11 month of treatment. Study Findings:
Most patients after surgery have significantly
improvement in the clinical signs and the quality of life
in comparison to the time before surgery. Average
score of Koos reached 86.47 points postoperatively,
the average VAS postoperative mobilization score
reached 1.78 points. Conclusion: Treatment of early
stage knee osteoarthritis by laparoscopic surgery and
microfracture acquires good result and significantly
improves the symptoms after surgery.
Keywords: Knee osteoarthritis, microfracture
(MF = Micro fractures), VAS scale, Koos scale.
DAT VAN DE
THKG la banh ly do qua trinh r6i loan chuyen hOa,
lam mat can bang giu'a tong hap va huy hopi cua sun
va xuang &rad sun gay bong, mat clan sun khap, sun
khap kh6ng co kha nang tu' phuc hOi do khong co
mach nu6i. Ma nguyen nhan do tac d6ng co hoc va
yeu to co. the nhu': di truyen, phat trien, chuyen hoa
va chan thuang [1]. Theo thong ka nam 2010 tai
co khoang 13% dan so tren 60 tuoi co cac triau
chirng cOa THKG. Tai Viet Nam thoai h6a khdp
chiem 10,41% trong cac banh 19 xuang khap [2]. T9
le benh nhan THKG goi ngay cang tang t9 la thuan
vai di) tang cua tuoi tho, t9 le nguai tang can va beo
phi nOi Chung. CO nhieu phuang phap dieu tri THKG

toy thuOc vac) giai doan banh nhu' dieu tri nOi khoa kat
hop phuc hOi chi:rc Wang, Om can, nOi soi, thay
khap. THKG
giai doan I va II duac dieu tri khong
phau thuat (it nhat 6 thang) nhung khong cai thian
cac triau chirng lam sang thi chi dinh ph5u thuat nOi
soi duac xem xet de giai quyet tinh trang banh.
Ph5u thuat nOi soi dieu tri cac ban', ly khap gOi
11 nam tra lai day tai Viet Nam ngay cang phat then.
Banh vin Xanh P6n da ap dung phu'o'ng phap nOi
soi tao ton thuang dual sun dieu tri thoai hem gOi
nhieu nam nay, nhu'ng chu'a co bao cao nao danh gia
ket qua dieu tri cua phuang phap. Chung toi tien
hanh de tai "Nhan xet ket qua dieu tri thoai hoa khap
gal bang phu'o'ng phap nOi soi tao ton thu'o'ng dual
sun" nham muc Bich danh gia ket qua ye chirc nang
cung nhu• muc dO. hai long cua banh nhan sau phau
thuat theo thang diem VAS va KOOS.
DOl TU'O'NG, PHU'O'NG PHAP NGHIEN COU
- Doi twang nghien ciru: GOm 27 banh nhan dieu
tri tai Banh vin Xanh P6n trong khoang thai gian to
thang 9/2015 den thang 10/2010.
+Tieu chuan
chon:
1. Dau ( Pain —P)
2. Trieu cht:rng tai g6i ( Symptoms —S)
3. Sinh hoat hang ngay (Acticities 6 Daily Living- A)
4. The thao (Sport- SP)
5. Ch6t luting cuoc song (Quality of life —Q)

66

Banh nhan &lac chan doan THKG dO I, II (theo
tieu chuan cua Kellgren-Lawrence) [3].
Khong CO cac banh ly chOng chi dinh PTNS
Banh nhan duac theo clai sau phau thuat vai theii
gian tOi thieu la 3 thang
Phu'o'ng phap nghien cirul
theo phuang phap tien cuu, mo to
+ Nghien
khong nhom chirng.
+ K9 thuat PTNS: Lam sach khdp gOi bang PTNS,
lay b6 di vat va x6. ly cac ton thuang. Khoan hoac dui
nhang 16 nh6 vao xuang tai vung bi mat sun .
+ Danh gia ket qua sau phau thuat bang thang
diem VAS 6. thai diem 1 thang, 3 thang, 6 thang, 9
thang, 11 thang, va thang diem KOOS 6. thai diem 3
thang, 6 thang. 9 thang, 11 thang.
Thang diem VAS: la thuac do mirc dO dau cua
banh nhan, ap dung cho nguai Ian. Tren thang diem
do ca 10 mac do dau tir 0-10, tu'o'ng Ong muc dO
nang [4].
dau
nhe
0- khOng dau
1- Dau rat nhe, hau nhu' khOng cam nhan va nghi
den no
2- Dau nhe, thinh thoang dau nhoi de cam nhan
3- Dau lam riguai banh ch0 y, mat tap trung trong
cong viec, CO the thich &rig vai no.

4- Dau vira phai, banh nhan CO the quen di can
dau neu dang lam viec.
5- Dau nhieu han, banh nhan kh6ng the quen dau
sau nhieu phut, van co the lam viec.
6- Dau nhieu anh huang den cac sinh hoat hang
ngay, kh6 tap trung
7- Dau nang, anh hu.ang den cac giac quan va
han the nhieu den sinh hoat hang ngay cua banh
nhan. Anh huang den giac ng6.
8- Dau du. clOi, han the nhieu hoat dOng, can phai
no It.rc rat nhieu.
9- Dau kinh khong, khoc, kho kiem soat.
10- Dau khong the not chuyen &rot, nam hat
givang va co the me sang.
Thang diem KOOS: Danh gia chirc nang khap gOi
sau phau thuat 3 thang, 6 thang, 9 thang va sau 11
thang dcra vao thang diem KOOS (Knee Injury and
Osteoarthritis Outcome Score) [5]
Cau triic thang diem KOOS: la bO cau hal (Om 42
cau) phong van nguai banh ye chCrc nang cua khap
gOi, gOm dau gOi (9 cau); cac triau chCrng tai goi (7
cau); kha nang sinh hoat hang ngay (17 cau): kha
nang Choi the thao (5 cau); chat luvng cuoc song (4
cau). MOi cau hoi duuc chia lam 5 mirc dO
nhe
den nang, twang Ong vai diem tu• 0 - 4. Hinh thi:rc
danh gia:. phong van tru.c tiep, qua dien thoai, qua
email. Diem KOOS, duac tinh theo cong thirc sau:
Theo do, tong s6 diem cang cao chirc nang khap gOi
cang &Jac cai thian.

(100 — tong diem tir P1-P9 x 100)/36
(100 — tong diem tir S1-S7 x 100)/28
(100 — tong diem tir A1-A17 x 100)/68
(100 — tong di6rn tir SP1-SP5 x 100)/20
(100 — tong diem tir Q1-04 x 100)/16

Y 119C TH VC HANH (1026)- SO 11/2016


KET QUA NGH;EN COU
1. DOc diem nhom d6i twang nghien ciru
1.1. DOc diem tuOi, gibi, nghe nghiep, BMI va
then gian phat benh

Bang 1. Phan bo BN theo tu6i, gibi, nghe nghiep
Dac diem

Tu6i

Gi61
Lien quan
nghe nghiep

40 - 49
50 - 59
60 - 70
Nam
NC,
Lao Ong chan tay
Lao dOng tri 6c

T6ng s6 d6i tuvng
nghien cCru (n = 27)
n
26
7
37
10
37
10
25,9
7
74,1
20
63
17
37
10

Nhan xet: D6 tu6i trung binh la 55,78 ( 41-67).
NhOm tu6i chiem tit le cao nhat la tir 50- 59 tu6i va
nhOm 60- 70 tali (37%), nh6m tu6i tir 40-49 tu6i
chiem ti le that) nhat la 26%.
chiem 74,1 %, cao
Tjf le nu' giod trong nghien
han so vai nam gibi (chi chiem 25,9%). NO' nhieu
han nam vai tjt le la 3:1.
Ket qua nghien cOu cho they, nhOm doi tuvng
tham gia nghien ciru la lao d6ng chan tay chiem hi le
63%, cao han nhOm doi tuvng lao dOng tri tic (chiem

37%).

Nhan xet: Thong ke cho they, tat ca benh nhan
trong nh6m nghien ciru deu có trieu chirng dau gOi.
Trieu chirng "lyc cyc khap gOi" chiem 92,6 %, dau
hieu "cirrig gOi bu6i sang" chiem 74,1%. CO 1 benh
nhan c6 dau hieu bao gó chiem 3,7%.
1.3. Diem VAS trutec mO hai trang thai van
dOng Ira nghi ngai

Bang 3: Diem VAS tru,ac mO
Diem VAS trung binh
Trang thai
5,07 ± 0,68
Van dOng ( n = 27)
2,56 ± 0,51
Nghi ngai (n= 27)
NhOn )(Of: MUc d6 dau theo VAS khac nhau a hai

trang thai van d6ng va nghi ngai. C trang thai van
d6ng, diem VAS trung binh là 5,07 ± 0,68. Y trang
thai nghi ngai, diem VAS trung binh la 2,56 ± 0,51.
1.4. Chem 'hang Mop gOi trutec mO theo KOOS

Tronp cac hoat d6ng lien quan den chirc nang
khap goi thi chat luting cuOc song bi anh Wang
nhieu nhat vai diem KOOS trung binh la 28 ± 13,24.
Hoat ding the thao co KOOS trung binh chi dat 33,7
± 8,62. Cac trieu chirng tai vung gOi vol KOOS trung
binh 38,35± 7,26. Trieu chi:mg dau (KOOS = 41,47

±11,02) ,hopt Ong hang ngay (KOOS = 44,47 ± 9,6).
1.5. Phan lopi thoai hoa khOp gOi

Bang 4. Phan lop' thoai h6a gOi
Phan loai THKG
THKG nguyen phat
THKG thin phat

1.2. Nhikng bleu hien lam sang chinh cua
nh6m benh nhan nghien caw

Bang 2. Cac bieu hien lam sang chinh
Trieu chirng
Dau g6i
CI:mg goi buoi sang ( < 30 phOt)
Tieng lyc cyc khap g6i
Dau hieu bao g6

VAS nghi ngai
VAS van Ong

Trithc mo
(n=27)
2,55
5,07

0/0

27
20

25

1

SM1 thang
(n=27)
2,22
4,85

100
74,1
92,6
3,7

Trutec m6 (n=27)
SM 3 thang (n=27)
SM 6 thang (n=24)
SM 9 thang (n=10)
SM11 thang (n=4)

Dau g6i
41,47
62,04
81,25
93,89
97,9

KOOS trung binh

SM6 thang

(n=24)
1,21
2,13

SM9 thang
(n=10)
0,7
1,5

SM11 thang
(n=4)
0
1

vai Ian danh gia truac dO.
* Cai thien chirc nang khap gOi
Bang 6. Cai thien chin nang khap gOi theo KOOS

Trieu chirng tai g6i Sinh hoat hang ngay
38,35
44,77
51,06
63,9
79,36
59,65
91,17
65,36
94,47
65,17

Nhan xet: Ti' bang 65 cho they, chirc nang khap
gOi duvc cai thien r6 ret sau mO 3, 6, 9, va 11 thang
(p<0,05). Trong dO Lieu chi:mg dau a benh nhan la
cai thien tot nhat. Sinh hoat hang ngay, chat luvng
cuOc song va kha nang the thao cOng cai thien

55,56
44,44

Nhan xet: Theo thong We bang 4 cho they, nhom
dOi tuvng THKG nguyen phat chiem 55,56%. Nhorn
doi tuvng THKG thir phat chiem 44,44%.
2. Wet qua dieu tri
* Cai thien tinh trang dau khap
Bang 5. Cai thien tinh trang dau theo thang diem
VAS

SM3 thang
(n=27)
1,55
2,93

Nhan xet: TO' bang 5 cho they tinh tranh dau duvc
cal thien ro ret tai cac thai diem danh gia. Tai thai
diem danh gia sau, tinh trang dau cai thien han so

15
12

The thao

33,7
51,67
70,83
83,5
92,5

Chet krang CS
28,01
48,15
68,75
83,13
82,81

nhanh. Cac trieu chirng tai gOi thay d6i cham, do chU
yeu cai thien a tinh trang sung gOi va Nen d6 van
dOng gOi.
Bang 7. Diem KOOS trung birth trtyac va sau mO

Triyac m6 (n=27) SM 3 thang (n=27) SM 6 thang (n=24) SM 9 Thang (n=10) SM11 thang (n=4)
37,26
71,97
55,36
83,41
86,47

Y HQC THVC HANH (1026)- S6 11/2016

67

BAN LUAN
1. D'ac diem cua nhom bOnh nhan nghien aru
Theo uac tinh cua TO chirc Y to The giai, tren the
glad vac) nam 2000, tY la THKG tai M9 tY la THKG gay
triau chCrng chiem khoang 4,9% nguai Ian tren 26
tuOi, 16,7 % ngubi tren 45 tuOi va 12,1% nguai tren
60 tuOi [6,7]. Do do tuOi cang cao tY la THKG cang
tang. Trong nghien cCru cua chung tai, Om 27
banh nhan, nhom banh nhan tren 50 tuOi (chiem
74%). TuOi tir 40-49 co tY la 26%. MOt nghien cCru
cua Muraki va Ong scr, cOng nhu' nhieu nghien
cCru khac deu thay rang, tY le THKG a nir giai 'Lion
cua
cao han nam giai [8,9]. Tron9 nghien
chung tali, SO banh nhan nu' chiem tY la 74,1 % gap
gan 3 In sO banh nhan nam. Nghe nghiap anh
huang tinh trang THKG cho yeu la theo thuyet ca
hoc do nhieu nghanh ripe co tu' the lao dOng khong
thuan lai .cho khap goi, hay do chan thuang vOng
trong gOi gay mat
gOi lam ton thuang cac to
yang khap gOi lam gia tang Ivo tai len khap gOi, dan
den khap nhanh thoai hoa [10]. Trong nghien
cCru cua chtIng tai, tY le THKG cua nh6m lao dOng
chan tay (chiem 63%) cao ban nhOm lao dOng bang
tri 6c (chiem 37%). Trong nghien CO'Ll cua chOng tai
co 55,56% banh nhan THKG do char) thuang.
2. Ket qua
Sau mot 1 thang 96i a trang thai nghi ngai VAS
trung binh tO. 2,55 xuong 2,22, a trang thai van dOng

diem VAS Om 5,07 xuong 4,85. Dau hiau dau gOi ae
ca hai trang thai duvc cai thin sau mO do to chCrc
thoai hoa duvc loaf b6, cac yeu to ton thu'ang duvc
cua chung tali CO tren 90%
xCr ly. Trong nghien
banh nhan co ton thuang ph& hap. TO' thang thir 6
sau mO,.tinh trang dau du'ac cal thian r6 rat so vai
truac mob ca hai trang thai nghi ngai va van dOng,
diem VAS deu Om co y nghia (p<0.05).
Danh gib chirc nang khap gOi theo thang diem
KOOS, theo do diem cang cao chCrc nang khap gOi
cang duvc cai thian. Diem KOOS trung binh chung
tang theo thai gian, trong do tang manh nhat sau mot
6 thang, do hai tac dOng la nOi soi lam sach khap gOi,
va sty hinh thanh m6 sun mod tai vOng tao ton thu'ang
&rod sun. Sau mO 9 den 11 thang tinh trang gOi tiep
tuc du'oc cat thien chirng to vai trot cua sun khap mai
phuc hai. Dong thai ket hap vai su, tang cuang tap
luyan, van dOng gOi va the dO an uOng cua banh
nhan giCip chik nang gOi cua ho ngay cang duvc cat
thian.
Thai gian theo dOi trung binh sau mO va do lech
chuan cua chUn9 Col la 7,07 ± 3,05 thang, thai gian
theo cloi con ngan va sO luvng banh nhan phi] hap
chu'a nhieu cho thay day chi la ket qua kha quan
buck dau cua qua trinh phau thuat.
KET LUAN
Benh ly THKG da sO a lu.a tuOi trung nien. Nhung
do siy phat trien xa hOi nen thoai hoa khap ngay cang
tre hoa, do yeu to nghe nghiap, beo phi, chan

68

thu'ang, thai gian banh keo dais Cac banh nhan du'ac
ph5u thuat not soi va tao ton thiyang duai sun sau
mot du'ac danh gia bang thang diem dau VAS va
danh gia chtk nang khap theo thang diem KOOS
deu cho ket qua buac dau kha quan cua phu'ang
phap. VAS van dOng trung binh trisac mot dat 5,07
diem, sau mO trung binh tat ca banh nhan dat 1,78
diem. The hien mCrc dO dau cai .thian rat tOt sau mO.
Chirc nang khap theo thang diem KOOS trung binh
trirac mot dat 37,26 diem, KOOS trung binh sau mot 6
thang la 71,97 diem, 11 thang la 86.47 diem. Sau m6
chirc nang khap gOi cai thin tOt so vai thai diem
truac mO rat nhieu. Hai thang diem VAS va KOOS rot
ranh, chi tiet, nen banh nhan de hieu va cCmg de to•
danh gia chi tiet tinh trang tien then banh. Hai thang
diem nay cho phep to biet cluvc su' hai long ye chat
hyping cuOc song va phan loaf du'ac banh nhan sau
mO. Day mai la ket qua ngan han cua banh nhan sau
mO, can co sty theo clOi va danh gia xa han sau ph5u
thuat.
TAI LIEU THAM KHAO
1. Tren Ngoc An, Nguyen Thi Ngoc Lan (2000).

Dieu tri thoai h6a khdp va c6t sling. Di61.1 tri hoc niji
khoa. Nha xuat ban Y hoc, 2000; 212-224.

K M Jordan,et.al (2003). EULAR

2.
recommendations 2003: an evidence based approach to
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