BNH HOI T V MCH CHM XNG I NGI TRNG THNH

Bin san: Trnh Xun L

1/ nh ngha: Bnh hoi t v mch (Avascularnecrosis, vit tt AVN) chm xng i l mt
bnh l mch mu gy hoi t m xng do gim mu cung cp, tin trin dn gy h hi ton
b khp hng.
2/ Nguyn nhn cha r rng nhng c cc yu t nguy c:
- Cc bnh h thng (V d: Bnh v mu, bnh Lupus, bnh Gaucher)
- Ri lon chuyn ho cht khong v tc mch do Corticoid ni v ngoi sinh
- Chn thng (gy c xng i, trt khp hng)
- Do ru (Theo Matsuo, Sugioka nguy c s tng nu ung trn 400ml mi tun)
- V cn.
Lin quan n ru v Corticoid chim 90%
3/ C ch bnh sinh: Bnh biu hin bng nhng b xng cht, thay i ty xng lan dn
n di sn, thng vng trc ngoi ca chm xng i. Tn thong thng c dng hnh
nm. Du hiu tiu xng trn nn to xng, khng to xng trung tm m c to xng
khng hon ton ngoi bin, xng cht s dn c thay th bng m si v m ht. Do s
lng ong ca xng mi ln trn xng cht lm b xng dy ln to hnh nh trn XQ xng
chai v nang. Nu vng tn thng ln thng lu thng mu s khng hi phc, tn thng
tin trin dn xng hoi t v gy cc b xng cho n khi bp chm v h hi ton b khp
hng (chm v ci) chim 90% cc trng hp. Ch 10% c th t lnh li mt san thng
nh n nh.
4/ Phn loi:
Phn loi da trn XQ theo Ficat v Arlet gm 4 giai on
Giai on I:
Khe khp bnh thng
Chm xng i bnh thng
B xng trong chm bnh thng hoc long xng nh
Khng th chn on bng XQ, chn on bng x hnh xng, MRI.
Giai on II:
Khe khp bnh thng
Chm xng i bnh thng
B xng trong chm long xng r, trn ln vi xng x chai, nang xng (m ht)
Chn on c th da trn XQ nhng cn xc nh bng sinh thit .
Giai on III:
Khe khp bnh thng
Chm xng i b xp ln, thiu mu di sn gy sp.
B xng c xng cht
Giai on ny c th chn on bng XQ d dng. MRI gip chn on mc v v tr
tn thng.
Giai on IV:
Khe khp hp, chm sp nng, h hon ton, b xng b ph hu vng cc trn. C
c nang xng, chi xng, hy sn chm v ci.
Chn on bng XQ kh khn v kh phn bit gia thoi ho khp, vim khp v hoi t
chm giai on ny. i khi phi sinh thit chn on.
1

Khi c MRI, HUNGERFORD v LENOX a ra h thng phn loi Ficat ci tin gm: 0, I, II,
III, IV.
Giai on 0: ch thy trn MRI cho hnh nh ng i (Double-line) bnh nhn khng
c triu chng.
Giai on I: c triu chng, XQ m tnh, MRI dng tnh, x hnh +
Giai on II, III, IV: ging phn lai Ficat
STEINBERG m rng h thng Ficat v Arlet thnh 6 giai on: Trong c a thm tn
thng ci vo:
Giai on I: XQ bnh thng, c long xng hoc chai xng
Giai on II: XQ hnh nh tiu xng di sn to hnh li lim
Giai on III: XQ bt u c nh hng n chm, sp nh, mc tn thng 15%
Giai on IV: Tn thng chm, sp va 15%-30% cha c tn thng ci
Giai on V: Tn thng chm nng trn 30%, bt u c tn thng ci, thoi ho
tiu xng long xng, khe khp hp
Giai on VI: Tn thng ton b chm v ci, mt khe khp i khi dnh khp
Cc bc s Nht v Php a ra phn loi quc t cho hoi t chm (international classification):
Phn loi da trn v tr tn thng trn XQ .
Giai on 0: Tt c cc tests bnh thng ch c sinh thit cho thy hnh nh hoi t v mch.
Giai on I: XQ bnh thng, x hnh MRI +, tn thng chia thnh:
IA/ 15% tn thng pha trong
IB/ 15%-30% tn thng trung tm
IC/ 30% tn thng bn ngoi
Giai on II :XQ bt thng hnh nh mi n , chai xng , nang yu xng . cha sp
IIA/ 15% tn thng pha trong
IIB/ 15%-30% tn thng trung tm
IIC/ trn 30%
Giai on III: c tn thng hnh li lim, c ln mt khp, cha tn thng ci
IIIA/ Li lim chim 15%, ln di 2mm
IIIB/ Li lim 15%-30%, ln 2mm-4mm trung tm
IIIC/ Li lim trn 30%, ln >4mm pha ngoi ca chm.
Du lm sng v chn on:
Du hiu lm sng: Bnh nhn n khm v au khp hng, i khi au mng hoc gi.
au su c cm gic nhp p, au dai dng, au thng khi pht t t, au tng ln khi c
ng khp hng c chu lc, c bit l khi xoay trong. (i khi b c 2 bn, chim 50%-80%)
Mun hn bnh nhn s c dng i khp khin.
Cn lm sng:
1/ XQ: Phim thng trc sau : Thng cho thy 1 vng lin quan chnh; nhng v b ca
cho hay trng lp 1 phn chm trn nn nhng hnh nh mi nh ca x chai xng c th b
st. do XQ t th chn ch (frog leg) rt quan trng gip thy r vng ny. Phim nghing
thng khng cho kt qu tt v phn mm nhiu (nhng gip cho nh gi giai on bnh v
phn trc chm b trc).

2/ X hnh xng: Dng Tc99 Cho thy vng phn ng quanh ch thiu mu tng ly
ng v phng x trn mt phim chm (do cho thy 1 vng bt x km c bao quanh bi 1
vng tng bt x). X hnh s kh nhn ra khi b 2 bn giai on sm.
V vy ch nh x khi XQ (-) khng c yu t nguy c v b au 1 bn. Nu x (-) cn theo di.
3/ MRI: Mt s tc gi cho rng MRI l chnh xc nht chn on hoi t v mch.
Du hiu sm nht l:
- 1 ng m (trn T1 weighted) (cho rng l ranh gii phn bit xng lnh v xng
hoi t).
- Du ng i: (1 ng nm trn ng m trn T2 weighted do m ht tng mch
mu).
Ngoi ra MRI cn cho thy r ranh gii ca tn thng v cho thy nhng thay i ti lp mch
v p ng trong iu tr, cho php chn on nhng tn thng cha c triu chng m XQ (-).
Nhiu nghin cu thy MRI chch xc 93%-97%, ngha l 3%-7% trng hp MRI (-) nhng
sinh thit cho thy tn thng avascular (Koo report)
4/ nh gi chc nng xng: (C tnh cch lch s hin nay khng s dng na) o p
lc ty xng, chp tnh mch, sinh thit . Test ny cho nhy cm v c hiu cao. Tuy nhin
y l th thut xm ln, dng kim 3mm chc vo ch chm c o p lc (bnh thng < 30
mmHg) . Nu tng cao sau 5 chc kim (trung bnh 42,3 + - 6,8 mmHg l c hoi t v mch.
Lm stress test bng cch bm thm 5ml nc mui sinh l v p lc tng thm hn 10 mmHg l
c ngha chn on . Sau bm thuc cn quang v chp h tnh mch , bnh thng th 4 tnh
mch hin r nhanh sau 5 v thuc cn quang s i ht trong 5 .
5/ Sinh thit: Nghin cu m hc cho thy b xng vi nhng l trng gip chn on
hoi t xng. Tuy nhin phng php ny l can thip trn bnh nhn, hn na khi ta ly sai
ch tn thng s cho kt qu (-).
6/ CT scan: c tin, n tia, khng cn thit. Tuy nhin dng phn bit g II v g III
(g bt u ln chm v g tr ca ln chm)
Tiu chun chn on:
Tiu chun c hiu:
- Ln chm
- Du gim ca quanh vng di sn
- Hu xng trc ngoi
- X hnh c bao quanh bi vng tng x
- Di i trn T2 MRI
- Sinh thit (+) xng cht nhng l trng xng
Tiu chun khng c hiu:
- Ln chm v hp khe khp
- Du mi n to nang, c xng mt vng
- Tng hot ng trn bone scan
- MRI thay i c ph v x ho
- au khi vn ng hng, hn ch vn ng khp v xoay trong. C tin s ung ru,
corticoid.
- Bt thng trn sinh thit thy: tu xng ph n v x ho
5/. iu tr:

Khng m: Theo di v khng chu lc. Thng nghin cu cho thy tin lng thng
xu vi bnh ny. Khong >85% xp chm sau 2 nm t khi c triu chng giai on I, II nu
khng iu tr. Thng ch nh khi bnh nhn khng th phu thut, tn thng nh <15% nm
vng t hoc khng chu lc.
PHU THUT :
1. Ghp xng cng khng c mch nui: Thng dng xng mc. Kt qu tt, sau 5 nm
thay i t 50-80%
2. Ghp xng khng mch nui trc qua chm c: Kt qu tng t nh trn.
3. Ghp xng c mch nui:
- Ghp xng mc c cung mch nui bng vi phu thut.
- Ghp xng mo chu c cung mch nui cng bn.
C 2 phng php ghp xng c mch nui u cho kt qu rt tt, trng hp tn thng
giai on sm cho kt qu tt sau 15-20 nm l trn 90% vi iu kin phu thut giai on
sm, chm cha bin dng, sn chm cha h.
4. c m xng chuyn v tr chu lc (osteotomy): kt qu tt thay i t 50-70%.
Nhng c vn l khi cn thay khp thng gy kh khn do dnh ca phu thut trc.
5. Thay chm ton phn: p dng cho nhng trng hp n mun, tn thng ph hy c
chm v ci. Hoc cho nhng trng hp iu tr bng cc phng php trn tht bi.