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IEU TR BU SUN LANH BAN TAY

Le Van Tho (1), Le Ch Dung (2) ai Hoang An (3), Le Vu Quoc Hien (3), Bui Hoang Lac (3)

T khoa: Bu sun lanh: Enchondroma; Hnh anh y hoc: Medical Imaging; May mai cao toc: High Speed Burr.

TOM TAT Trong 5 nam t thang 05/1997 en 07/2002 Khoa Benh hoc C Xng- Khp Benh

vien Chan Thng Chnh Hnh thc hien phau thuat cho 72 trng hp bu xng ban tay, trong o co 45 trng hp bu sun lanh. Cac bu khac t gap hn gom 12 bu sun xng, 5 bu ai bao xng. Ba trng hp bu co o ac thap bao gom: 1 sarcom mang xng, 1 sarcom sun trung tam, 1 sarcom sun ngoai vi th phat.

Bu sun lanh la loai bu hay gap nhat ban tay, chiem ai a so cac trng hp. Viec chan oan can da vao s ket hp cua giai phau benh lam sang hnh anh y hoc. Van e ieu tr can phai co s phoi hp tch cc gia phau thuat va vat ly tr lieu sau mo e at c ket qua ieu tr tot nhat.

Cac phng phap ieu tr chu yeu cua bu sun lanh gom: Nao bu + ghep xng : 31 ca. Cat rong bu + ghep xng + xuyen kim : 11 ca. Cat tron bu n thuan : 01 ca. Cat bo ot ngon tay : 01 ca. Ch thc hien sinh thiet : 01 ca. Ket qua theo doi t 14 thang en 74 thang (trung bnh 40,9 thang) cho thay:(1) ket qua

tot ve mat ung bu hoc, tat ca eu lanh xng. 2 trng hp tai phat do nao con sot bu; (2) ket qua ve chc nang cua ban tay con khiem ton; (3) 1 trng hp b nhiem trung sau mo c ieu tr lanh bang khang sinh va san soc vet thng.

T o cho thay nhng van e con ton tai :(1) vat ly tr lieu sau mo cha c phat huy triet e; (2) thay khp nhan tao ban tay can c trien khai rong rai va phat trien e gop phan nang cao chat lng ieu tr.

SUMMARY Management of enchondromas of hands

Le Van Tho et al

During 5 years (May 1997 July 2002), at the Orthopaedic Diseases & Oncology Department, Hospital For Traumatology & Orthopaedics Ho Chi Minh city, 72 bone tumors of hands are treated surgically including 45 enchondromas, 12 osteochondromas, 5 giant cell tumors .There are 3 low grade malignant tumors (2 chondrosarcomas, 1 periosteal sarcoma )

Enchondromas are the most common bone tumor of the hand. Diagnosis should be based on the combination of pathology, clinics and radiography. The treatment needs intimal collaboration between surgery and physical therapy in order to get the best result.

Surgical methods for Enchondromas include: (1) Thac s, Bac s ieu tr, Khoa Benh hoc c-xng-khp, BV CTCH TP HCM. (2) Pho Giao s, Tien s, Bac s Trng khoa Benh hoc c-xng-khp BV CTCH TP HCM. (3) Bac s Khoa Benh hoc c-xng-khp BV CTCH.

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Curettage + bonegraft : 31 cases Wide resection + bonegraft : 11 cases Marginal resection : 01 case Amputation : 01 case Biopsy only : 01 case

With the follow-up average period of 40,9 months (from 14 months to 74 months), the results show that: (1) good results in bone healing, two cases of recurrence due to incomplete removal of the tumor tissue. (2) Hand functions are still limited. (3) 1 case infection cured by antibiotic and nursing care.

There are 2 remaining problems: (1) physical therapy should be performed more actively. (2) Arthroplasty of the digit should be applied and developped to enhance the treatment quality.

AT VAN E MUC TIEU NGHIEN CU Bu xng ban tay tng oi hiem gap so vi cac v tr khac trong c the, bu ac

xng ban tay cang hiem gap hn [1][2][9][12][18][23]. a so cac bu la lanh tnh, trong o chu yeu la bu sun lanh (tren 60%)[2][3][12]. V vay, van e ieu tr thng mang lai ket qua tot ve mat ung bu hoc va kha nang lanh xng. Tuy nhien, ban tay la c quan gi nhieu chc nang quan trong, ac biet la cac ong tac cam nam. Do o muc ch cua ieu tr la khong nhng lay het bu ma quan trong la phai phuc hoi chc nang cua ban tay sau phau thuat. ay la van e can phai co s phoi hp chat che gia cac nha phau thuat ung bu, chan thng chnh hnh, phuc hoi chc nang e ieu tr at c ket qua tot nhat.

Theo quan iem cua nhieu tac gia [2][11][15], bu sun lanh thuoc nhom co nguon goc t mo sun va theo LE CH DUNG [9][10][11], bu nay c xep vao loai bu lanh oi khi hoa ac. Chnh v vay, trong ieu tr cac tac gia a co nhieu phng phap phau thuat khac nhau c thc hien, nh: (1) Cat rong bu ghep xng xuyen kim; (2) Nao bu ghep xng; (3) Nao bu n thuan; (4) Cat bo ngon tay; (5) Mot so t trng hp ch e yen va theo doi.

Gan ay, mot so tac gia a ap dung nhng phng phap phau thuat vi ky thuat mi nh nao bu bang noi soi khong ghep xng, ieu tr ho tr bang laser CO2, s dung hydroxyapatite, xi mang xng v.v nham muc ch nang cao chat lng ieu tr ngay cang tot hn.

Van e at ra la khi nao se ap dung phng phap phau thuat nao cho phu hp nham at c muc tieu: lanh xng tot, khong tai phat va hoa ac, am bao chc nang cua ban tay. Muc tieu nghien cu:

Gop phan nghien cu bu sun lanh ban tay, e tai nay nham 4 muc tieu: + Khao sat ve xuat o cua bu sun lanh ban tay. + Khao sat ac tnh lam sang, hnh anh y hoc, giai phau benh cua bu. + anh gia ket qua cua cac phng phap ieu tr phau thuat a thc hien, so sanh vi

ket qua cac tac gia khac, t o a ra ch nh ieu tr phu hp, hieu qua nhat, va am bao phuc hoi chc nang ban tay trong ieu kien hien nay.

+ Xem xet van e con ton tai va hng phat trien e nang cao chat lng ieu tr benh nhan cho hien tai va trong tng lai.

oi tng phng phap nghien cu: oi tng: Bao gom 45 trng hp bu sun lanh ban tay (gom 42 ca bu 1 ni va

3 ca bu nhieu ni) c ieu tr tai Khoa Benh hoc C-Xng-Khp Benh vien Chan Thng Chnh Hnh trong hn 5 nam, t thang 05/1997 07/2002 vi ay u ho s ve lam

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sang giai phau benh hnh anh y hoc (chu yeu Xquang), vi thi gian theo doi trung bnh: 40,9 thang (t 14 thang en 74 thang).

Phng phap nghien cu: Hoi cu anh gia ket qua ieu tr: da vao cac yeu to sau: + Van e lanh xng ghep va tai phat cua bu: da vao tieu chuan anh gia cua

Tordai [22] e xuat nam 1990. + Van e hoa ac. + Bien chng: Van e nhiem trung sau mo, ton thng gan + Van e chc nang:

KET QUA

Xuat o cua bu sun lanh so vi cac loai bu khac ban tay:

Stt Bu xng Nam N Tong cong 1 2 3 4 5 6 7 8 9

10 11 12 13

Bu sun lanh Bu sun lanh nhieu ni Bu sun xng Bu ai bao xng Choi xng di mong Bu sun mang xng Bu lanh xng dang xng Loan san si sun cua xng Boc xng n oc Boc phnh mach xng Sarcom mang xng Sarcom sun trung tam Sarcom sun ngoai vi th phat

11 2 2 2 0 0 0 1 1 1 1 1 1

31 1

10 3 2 1 1 0 0 0 0 0 0

42 (58,3%) 3 (4,2%)

12 (16,7%) 5 (6,9%) 2 (2,8%)

1 (1,39%) 1 (1,39%) 1 (1,39%) 1 (1,39%) 1 (1,39%) 1 (1,39%) 1 (1,39%) 1 (1,39%)

Tong cong 23 49 72 (100%) Nhan xet: Trong cac bu xng ban tay, bu lanh chiem a so (69 ca # 95,8%),

trong o bu sun lanh (1 ni, nhieu ni) hay gap nhat (45 ca # 62,5%). Hai loai khac co the gap la bu sun xng (12 ca # 16,7%), bu ai bao xng (5 ca # 6,9%). Cac loai khac rat hiem gap. Phan bo theo tuoi, gii cua bu sun lanh ban tay:

Tuoi Gii 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 Tong cong (%)

Nam 7 4 0 2 0 13 (28,9%)

N 6 5 11 9 1 32 (71,1%)

Tong cong (%)

13 (28,9%)

9 (20%)

11 (24,45%)

11 (24,45%)

1 (2,2%) 45 (100%)

Nhan xet: @ Bu hay gap n nhieu hn nam (t le 2,46 : 1). @ Tuoi hay gap : 15 45 tuoi (ln nhat: 51; nho nhat: 11).

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Phan bo theo v tr: Nhan xet:

Khao sat theo ot ngon: ot gan thng gap nhat (29 bu # 56,9%), ke en la ot gia (10 bu), xng ban (9 bu), ot xa hiem gap (3 bu # 5,9%).

Khao sat theo ngon: ngon IV, V thng gap nhat, ke en la ngon II, III, ngon I hiem gap (4 bu # 7,8%). Trieu chng lam sang: Thi gian t luc co trieu chng en khi kham benh:

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Anh 2.1A: Lam sang: bu sun lanh vung ot gan ngon tay tro

Anh 2.1B: Ton thng dang lech tam, XQ o IB

Anh 2.1C: ai the: bu nhn thay nam trong tuy xng sau khi m ca so xng

Anh 2.1D: Vi the: tang sinh te bao bu tao chat dang sun hyalin

Anh 3.5: Lam sang, XQ, ai the, vi the cua bu sun lanh Cac phng phap phau thuat:

Nao bu ghep xng : 31 ca Cat rong bu ghep xng xuyen kim : 11 ca Nao bu n thuan : 01 ca Cat bo ot ngon tay : 01 ca Sinh thiet : 01 ca

anh gia ket qua ieu tr: Ket qua XQ sau cung: Theo Tordai, 44 ca theo doi c anh gia nh sau: + Nhom 1: 40 ca (91%). + Nhom 2: 3 ca (6,8%), trong o co 1 ca nghi ng tai phat . + Nhom 3: 1 ca (2,3%), tai phat do nao con sot bu xay ra BN n 51 tuoi. Ket qua ieu tr theo tng phng phap:

Phng phap nao bu ghep xng: 31 ca + Lanh xng ghep: 100%. + Tai phat: 1 ca, do nao con sot bu; 1 ca nghi ng tai phat ang theo doi. + Khong co trng hp nao hoa ac. + Chc nang: @ Tot: 24 ca (77,4%). @ Kha: 4 ca (12,9%). @ Kem: 3 ca (9,7%).

Phng phap cat rong bu ghep xng xuyen kim: 11 ca + Lanh xng ghep: 100%. + Khong co trng hp nao tai phat hay hoa ac. + Bien chng: 1 ca b nhiem trung sau mo, c cha lanh bang khang sinh va san

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soc vet thng. + Chc nang: @ Tot: 0 ca (0%) @ Kha: 4 ca (36,4%). @ Kem: 7 ca (63,6%).

Phng phap nao bu n thuan: 1 ca Ket qua lanh xng tot, khong tai phat hay hoa ac, chc nang at ket qua tot .

Phau thuat thao khp lien ot xa ngon V: 1 ca. Ket qua theo doi khong tai phat hay hoa ac, chc nang sau mo tot.

Phau thuat sinh thiet: 1 ca (bu sun lanh nhieu ni). Ket qua GPB: bu sun lanh. Benh nhan t bo ieu tr, khong theo doi.

Nhan xet: Hau het cac phng phap eu cho ket qua lanh xng tot, khong tai phat va hoa ac. Tuy nhien, phng phap nao bu ghep xng cho ket qua chc nang tot hn nhieu so vi phng phap cat rong bu ghep xng xuyen kim. Ket qua anh gia chc nang c tom tat trong bang sau:

Stt KQ. chc nang

PP.Phau thuat Tot Kha Kem

Tong cong

1 Nao bu ghep xng 24 (77,4%) 4(12,9%) 3 (9,7%) 31 ca

2 Cat rong bu ghep xng xuyen kim

0 (0%) 4(36,4%) 7 (63,6%) 11 ca

3 Nao bu n thuan 1 (100%) 1 ca 4 Cat bo ngon tay 1 (100%) 1 ca 5 Sinh thiet Khong theo doi 1 ca

anh gia chc nang cac trng hp gay benh ly, thi iem phau thuat:

Chc nang PP.phau thuat Thi iem phau thuat

So caTot Kha Kem

Di 1 thang 2 2

Nho

m

1 Cat rong bu ghep xng xuyen kim (6 ca) 1,5 4 thang 4 2 2

Di 1 thang 7 4 2 1

Nho

m

2 Nao bu ghep xng (15 ca) 1,5 4 thang 8 5 1 2

Nhan xet: Trong cac trng hp gay benh ly, chung toi nhan thay: + Nhom benh nhan c ieu tr bang nao bu ghep xng van cho ket qua chc nang tot hn nhieu so vi nhom c ieu tr bang cat rong bu ghep xng. + Trong nhom 2: ket qua anh gia chc nang cho thay khong co s khac nhau co y ngha gia 2 thi iem phau thuat (p < 0,05).

BAN LUAN: S lc ve nguon goc mo hoc va benh sinh:

Bu sun lanh la loai bu tan sinh lanh tnh co nguon goc mo sun tao ton thng trong khoang tuy cua xng. Sang thng nay c coi nh xuat phat t o te bao sun lac cho va gay ton thng vung au than xng bnh thng. Ngoai ra, Levy va cong s cho rang

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loai ton thng nay con co nguon goc t mo tha dang bu [6]. Theo LE CH DUNG, bu nay c xep vao loai bu lanh oi khi hoa ac

[9][10][11], thng thanh sarcom sun. Mot so t trng hp bu sun lanh xay ra nhieu ni c goi la benh Ollier. Benh

khong di truyen, nguyen nhan do s roi loan phat trien trong qua trnh cot hoa noi sun, co y ngha khac biet ve mac sinh benh hoc vi bu sun lanh. Trng hp bu sun lanh kem theo bu mach mau mo mem goi la benh Maffucci. ay la cac loai benh co t le hoa ac kha cao, thanh sarcom sun. Van e ieu tr: anh gia ket qua ieu tr cua tng phng phap:

Do c xep vao loai bu lanh oi khi hoa ac [9][10][11], nen trong ieu tr muc tieu hang au la phai lay het toan bo mo bu, tranh nguy c tai phat va hoa ac.

Nghien cu hoi cu cua chung toi trong 5 nam t 1997 en 2002 co the c chia thanh 2 giai oan chnh: giai oan 19971999 va 2000-2002:

(1) Trong giai oan 1997-1999, chung toi a ap dung phng phap cat rong bu ghep xng xuyen kim cho hau het cac trng hp (11 ca). S d chung toi s dung phng phap nay la v: thi iem nay, do cha co may mai cao toc e lay het te bao bu con sot lai trong vach xng bao quanh mo bu neu nao se de sot bu, nguy c tai phat cao. Te bao sun c dinh dng chu yeu nh s tham thau. Neu nao de b ri rt te bao bu de tai phat.

(2) Sang giai oan 2000-2002, nh co may mai cao toc c a vao s dung, chung toi a ap dung chu yeu phng phap nao bu ghep xng cho hau het cac trng hp (31 ca). Cat rong bu ghep xng ch dung cho cac trng hp bu giai oan 3.

Chnh v tat ca nhng ly do tren, trong nghien cu nay chung toi se tach rieng tng phng phap phau thuat va anh gia ket qua ieu tr theo tng phng phap khi so sanh vi cac tac gia khac.

Phng phap cat rong bu ghep xng xuyen kim: Phng phap nay co mot u iem ln la lay het toan bo mo bu nh cat ma khong

cham bu, do o tranh c nguy c tai phat. Tuy nhien, viec tai tao lai cau truc xng bang ghep xng vo bac cau thng mang lai ket qua lanh xng cham va ket qua chc nang thng khong tot, ac biet nhng trng hp bu kch thc ln vung au xng nen khong gi c mat khp.

Mot vai tac gia trong y van co ap dung phng phap nay nhng thng ch khu tru nhng trng hp bu co kch thc ln, nhng trng hp can ieu chnh chieu dai cua xng benh hoac cac bu b tai phat sau khi nao bu ghep xng lan au [4][21].

Chung toi co 11 ca s dung phng phap nay trong giai oan 1997- 1999 (ap dung cho tat ca cac trng hp, khong phu thuoc XQ o IB hay IC). anh gia ket qua, thay rang:

Tat ca eu lanh xng tot, khong tai phat va hoa ac. Tuy nhien, ve thi gian lanh xng chung toi kho xac nh ro cu the v ay la mot nghien cu hoi cu.

Ket qua chc nang: Phau thuat cat rong oan xng mang bu phan ln eu khong gi c mat khp (7 ca) va d nhien ket qua chc nang cua nhom nay thuoc loai kem. So con lai (4 ca), nh cat rong nhng gi c mat khp, ong thi tap vat ly tr lieu tch cc sau mo nen ket qua chc nang at loai kha, khong co trng hp nao at loai tot.

Nhn chung, chung toi a at c muc tieu lanh xng tot nhng ve ket qua chc

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nang van con han che rat nhieu ma nguyen nhan chnh la viec cat rong bu phan ln a khong gi c mat khp, nhat la trong trng hp bu xay ra v tr xng nho ot ngon tay.

Nhan xet: Qua nhng ieu phan tch va anh gia c trnh bay tren, chung toi nhan thay rang viec s dung phng phap cat rong bu cho cac trng hp bu kch thc va va nho la qua mc can thiet. Phng phap nay ch nen ap dung cho cac trng hp bu kch thc ln, ton thng huy xng nhieu gay v vo xng xam lan phan mem (Xquang o IC). Tuy nhien, phau thuat nen co gang gi mat khp, tranh xuyen kim qua khp (neu co the c) hy vong se at c ket qua chc nang tot hn.

Phng phap nao bu ghep xng: ay la phng phap c nhieu tac gia chap nhan va s dung [2][6][17][21]. Theo Dorfman [2], trng hp bu sun lanh tai phat sau nao th van co the c

cha lanh bang phau thuat nao bu lan th 2. Tuy nhien, Giles [4] lai cho rang mot khi bu tai phat th nguy c hoa ac cua bu a tang len. Do vay, viec loai bo toan bo mo bu ngay t lan mo au la rat quan trong va can thiet.

Mot vai nghien cu trc ay [4][6] a co gang han che nguy c sot te bao bu bang cach ot khoang bu bang nhiet hay s dung hoa chat nh phenol, alcohol, nitrogen long hoac phau thuat ong lanh .vv sau khi nao.Tuy nhien, cac phng phap nay thng gay nhieu bien chng nh nhiem trung, gay xng, hoai t da, ngo oc, hoai t vach xng..

Viec ghep xng lap ay khoang trong mat xng a lam gia tang toc o lanh xng va phuc hoi o vng c hoc cua xng sau khi nao bu [7]. a so cac tac gia van thch dung xng ghep t than, ac biet la xng xop v dien tien qua trnh hoa nhap va thi gian lanh xng nhanh hn. ac biet, co vai tac gia cung a th dung loai xng ghep khac nh xng ghep ong loai ong kho [7] hoac xng ghep d loai [21] e thay the xng ghep t than. Nhn chung ket qua lam sang thng tot, nhng s hoa nhap xng ghep thng cham va kem, ac biet oi vi xng ghep d loai.

Trong lo nghien cu cua chung toi, ca 31 ca nao bu ghep xng eu cho ket qua lanh xng tot. Tai phat 1 ca do nao con sot bu, 1 ca nghi ng ang theo doi. Hau het cac tac gia eu cho rang nguyen nhan chu yeu gay tai phat la do nao con sot bu va ghep xng khong ay u. Phng phap nao bu thng e sot mot t te bao bu trong vach xng bao quanh mo bu. Trong vai thap nien gan ay, viec s dung may mai cao toc phoi hp vi bm ra nc nhieu lan nham muc ch e lam sach nhng te bao bu sau khi nao, nh o han che c toi a nguy c tai phat. Rieng chung toi ch mi bat au s dung may khoan mai nay t hn 3 nam gan ay. Ve thi gian tai phat, Montero [17] a ghi nhan 1 trng hp bu tai phat sau 6 nam ieu tr. Do o, ong e ngh rang 5 nam la thi gian toi thieu e theo doi nhng trng hp bu tai phat nay. Van e chc nang: Noi chung, cac nghien cu khac nhau cho thay phau thuat nao bu ghep xng a mang lai ket qua chc nang rat tot, tren 75%, phu hp vi nghien cu nay. Tuy nhien, chung toi co 3 trng hp chc nang xep loai kem, nguyen nhan chu yeu la do van e vat ly tr lieu sau mo khong tot va benh nhan khong tai kham theo doi.

Phng phap nao bu n thuan, khong ghep xng: Phng phap nay a c Jaffe, Lichteinstein [6][18] ap dung t nhng nam 1943. Tuy nhien, nhieu tac gia lai cho rang viec ghep xng se lam tang lc c hoc cua xng va gia tang toc o lanh xng sau khi nao bu. Do vay, ve sau nay nhieu tac gia khac cung a s

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dung phng phap nay nhng thng ch cho cac trng hp bu co dang lech tam [18][21], tat ca eu mang lai ket qua lanh xng tot, khong tai phat va hoa ac. Rieng chung toi cung co 1 trng hp bu dang lech tam xay ra ot gia ngon IV tay (T) benh nhan n, 26 tuoi. Ket qua sau khi nao bu n thuan, khong ghep xng rat tot, chc nang ban tay tr lai bnh thng.

Phng phap cat bo ot ngon tay: Phng phap nay ch ap dung rat han hu khi bu co kch thc qua ln (dang khong

lo), huy xng gay pha v vo xng xam lan phan mem nhieu (XQ o IC), ac biet la ngon tay b mat chc nang hoan toan. Rieng chung toi co 1 trng hp thao khp lien ot xa 1 benh nhan n, 44 tuoi. Benh nhan b bu sun lanh ot xa ngon V ban tay (P), kch thc qua ln, xam lan ra mo mem sat da khong the bao ton va chc nang cua ot xa ngon tay b mat hoan toan. Ket qua sau mo tot. Thi iem phau thuat cac trng hp gay benh ly: Gay benh ly la bien chng thng gap, chiem t le rat cao ( 40%) va thng la ly do khien benh nhan en kham. V vay, nhieu tac gia cho rang muc tieu oi vi ieu tr phau thuat bu sun lanh khong trieu chng ban tay la e ngan nga gay benh ly [8][14]. Mot van e at ra la thi iem mo nen tien hanh ngay sau khi gay hay ch i en khi xng gay lanh mi mo nao bu ghep xng? Cac tac gia Jobe MT [8], McVey MJ [14] eu thong nhat quan iem cho rang phau thuat nen c tr hoan cho en khi xng gay lanh, sau o mi tien hanh mo cat bu. anh gia ket qua 21 trng hp gay benh ly cua chung toi gia 2 thi iem phau thuat: trc 1 thang va sau 1,5 thang cho thay rang khong co s khac biet co y ngha ve ket qua ieu tr (p < 0,05). Tuy nhien theo quan iem cua chung toi, mo sm trong trng hp gay benh ly de xay ra kha nang nao con sot bu, hn na can xuyen kim co nh o gay de lam ton thng mat khp, anh hong ket qua chc nang ban tay sau ieu tr. Do vay, chung toi cung ong y vi quan iem cho rang: oi vi cac trng hp gay benh ly, nen ieu tr bao ton va ch cho xng gay lanh trc khi phau thuat nao bu ghep xng se cho ket qua tot. Nhng van e mi trong ieu tr bu sun lanh ban tay hien nay: Khoang hn mot thap nien gan ay, nh rut ta c kinh nghiem cua nhng ngi i trc, cung vi s phat trien cac phng tien ky thuat nh may noi soi, laser CO2, hydroxyapatite, xi mang.v.v, nhieu ky thuat ieu tr mi a c bao cao nh nao bu khong ghep xng, nao bu bang noi soi khong ghep xng, ieu tr ho tr bang laser CO2 hoac s dung cac chat thay the nh hydroxyapatite, xi mang xng.v.v va a chng to c tnh hieu qua, s phong phu va a dang trong viec chon la phng phap ieu tr cua loai bu nay. Trong khuon kho gii han cua bai bao cao nay, chung toi ch gii thieu ma khong trnh bay ky cac phng phap ke tren. Ch nh phng phap phau thuat va t duy ieu tr:

Da vao s phan tch, anh gia ket qua ieu tr cua nghien cu nay cung nh cua cac tac gia khac, so sanh u khuyet iem cua tng phng phap ieu tr neu tren cung nh tham khao nhng phng phap ieu tr mi, chung toi a ra nhng ch nh ieu tr thch hp cho tng nhom bu, phu thuoc vao cac ac iem cua bu va tien trien lam sang cua benh, phu hp vi hoan canh thc te va ieu kien hien nay:

(1) Phng phap nao bu n thuan: ap dung cho cac trng hp bu co kch thc

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va va nho, dang lech tam. (2) Phng phap nao bu - ghep xng: ap dung rong rai cho hau het cac bu co kch

thc va va nho. Rieng bu khong lo giai oan 3 can can nhac gia nao hoac cat rong tuy trng hp (*).

(3) Phng phap cat rong bu - ghep xng: ch ap dung cho cac trng hp bu dang khong lo giai oan 3 ma khong the cat het bu bang phng phap nao.

(4) Phau thuat cat bo ot ngon tay: ch ap dung han hu cho trng hp bu dang khong lo, mat chc nang ngon tay.

oi vi cac trng hp gay benh ly: ieu tr bao ton, ch xng gay lanh trc khi phau thuat nao bu ghep xng.

Cac trng hp nao bu: nen s dung may mai cao toc e tranh sot bu. Van e hoa ac: Bu sun lanh 1 ni:

Hau het cac tac gia eu cho rang t le hoa ac cua bu sun lanh ban tay la rat hiem gap ( 1%) [1][2][8][9]. Theo JOBE MT[8], rat kho chan oan c sarcom sun trung tam la nguyen phat hay th phat t cac sang thng san co nh bu sun lanh tr khi c chan oan bu sun lanh trong lan mo au va chan oan sarcom sun sau khi bu tai phat. Ve mat vi the, nhieu trng hp rat kho phan biet gia bu sun lanh va sarcom sun o I [2][10]. Do o, viec ket hp 3 yeu to giai phau benh lam sang hnh anh hoc trong cong tac chan benh la rat quan trong va luon luon can thiet. Bu sun lanh nhieu ni (benh Ollier):

Tuy theo tac gia, t le hoa ac cua benh co the thay oi t 10 50% [2][6][9]. Theo Dorfman [2]: benh nhan b bu the nhieu xng se de hoa ac hn benh nhan b the t xng. Benh thng t gii han va ngng tien trien khi tuoi trng thanh, mot so trng hp lanh xng t nhien [16]. Do vay, neu sang thng sun van tiep tuc hoat ong hoac gay au khi tuoi ln nen nghi ng kha nang hoa ac. Trong nghien cu cua chung toi, tat ca 44 ca theo doi (42 ca bu 1 ni va 3 ca bu nhieu ni) cha co trng hp nao co bieu hien hoac nghi ng hoa ac. ieu nay cung phu hp vi y van va cac tac gia khac ve t le hoa ac thap cua no. Tuy nhien, thi gian theo doi toi a cung ch 6 nam nen van e ket luan cung can co thi gian dai hn. Van e vat ly tr lieu sau mo:

ieu tr cac bu xng cua ban tay, ngoai ket qua lanh xng th van e phuc hoi chc nang la cc ky quan trong va mang y ngha chien lc. No cho phep anh gia mot cach toan dien chat lng cua cuoc ieu tr.

Cac trng hp c ieu tr bang phau thuat nao bu ghep xng ket hp vi tap vat ly tr lieu sm sau mo thng at c ket qua chc nang rat tot. Nhng benh nhan khong tap vat ly tr lieu sau mo tot hoac cac trng hp c phau thuat cat rong va bat ong lau sau mo a lam han che rat nhieu ket qua ieu tr ve mat chc nang. ay la van e can c nghien cu xem xet, nen co chng trnh tap vat ly tr lieu sau mo cu the, nhat la cac benh nhan xa, ieu kien tap han che.

Noi chung, phat trien va quan tam ung mc lnh vc phuc hoi chc nang la van e rat quan trong va khong the thieu trong nganh chan thng chnh hnh, ac biet oi vi chuyen khoa ban tay nham nang cao chat lng ieu tr ngay cang tot hn hien tai va trong tng

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lai. Van e thay khp nhan tao ban tay:

ay la van e nen c phat huy va phat trien cung vi muc ch nang cao chat lng ket qua ieu tr cho benh nhan.

ai a so cac bu sun lanh ban tay neu c phau thuat ieu tr ung phng phap va vat ly tr lieu sau mo tot thng mang lai ket qua lanh xng va chc nang ban tay c phuc hoi. Tuy nhien, mot so trng hp do benh nhan en tre, kch thc bu qua ln, ac biet cac bu dang khong lo, giai oan 3 khong the nao c. Phau thuat ieu tr can phai cat rong bu nguyen khoi va ghep xng bac cau, nhieu trng hp khong gi c mat khp. Hn na, sau mo thng phai bat ong lau, vat ly tr lieu cha phat huy het vai tro. Do o, han che va cng khp van con la van e nan giai trong ieu tr cac bu trng hp nay.

V vay, thay khp nhan tao ban tay e giai quyet chc nang oi vi cac trng hp neu tren la van e va mang tnh thi s, va mang tnh chien lc trong hng phat trien tng lai cua mot trung tam chuyen khoa nham ap ng c nhng han che neu tren.

KET LUAN Qua nghien cu tong ket 45 trng hp bu sun lanh ban tay c ieu tr, chung

toi thu nhan c nhng ket qua nh sau: 1. Xuat o: trong cac loai bu xng ban tay, bu sun lanh chiem a so (62,5%), n >

nam, tuoi thng gap t 15 45. 2. Chan oan: da vao vi the, phoi hp vi cac d kien lam sang va XQ. 3. ieu tr: chu yeu nao bu ghep xng thng cho ket qua tot. Phng phap cat rong

bu ghep xng ch ap dung cho cac trng hp bu kch thc ln, dang khong lo, giai oan 3.

4. Van e vat ly tr lieu va thay khp nhan tao ban tay Vat ly tr lieu sau mo ong vai tro quan trong va khong the thieu trong ieu tr. Thay khp nhan tao e giai quyet chc nang ban tay oi vi cac trng hp han che

va cng khp la hng phan au hien tai va trong tng lai.

TAI LIEU THAM KHAO 1. Culver JE, Sweet DE, McCue FC: Chondrosarcoma of the hand arising from a pre-

existent benign solitary enchondroma. Case report and pathological description. Clinical Orthopaedics and Related Research, No.113: 128-131, 1975.

2. Dorfman HD, Czernniak B (1998): Enchondroma. In Bone Tumors, Mosby, St. Louis, Chap.6, pp 253 296, 389394, 585 587

3. Gaulke R: The distribution of solitary enchondromata at the hand. J.Hand Surg.(Bm), 27B: 5: 444-445, 2002.

4. Giannikas AC, Athens, Greece: Treatment of metacarpal enchondromata, Report of three cases. J Bone Joint Surg, 48B: No 2, 333-335, May 1966.

5. Gingrass RP, Fehring BHT, Matloub H: Intraosseous wiring of complex hand fractures. Plast Reconstr Surg., 1980, 66(3): 383 394.

6. Jaffe HL: Solitary Enchondroma and Multiple Enchondromatosis. In Tumors and Tumorous Conditions of the Bones and Joints. Lea & Febiger, Philadelphia, Chap.11, 169-195, 1964

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7. Jewusiak EM, Spence KF, Sell KW: Solitary benign enchondroma of the long bones of the hand, Results of curettage and packing with freeze-dried cancellous-bone allograft. J Bone Joint Surg, Vol.53A: No.8, 1587-1590, 1971.

8. Jobe MT (1992): Tumors and Tumorous Condition of Hand. In Campbells Operative Orthopaedics (A.H. Crenshaw), 8th ed, Mosby Year Book, St. Louis, Vol 5, Chap. 77, pp 34553456.

9. Le Ch Dung: Bu lanh sun. Trong sach Bu Xng, 2003, Nha xuat ban Y hoc, 120 - 130

10. Le Ch Dung: Bu xng: ung th nguyen phat, bu lanh, Luan an Pho Tien s khoa hoc Y Dc, Trng ai Hoc Y Dc TP.Ho Ch Minh, 1995.

11. Le Ch Dung: Phan loai Bu xng, nghien cu 1455 t.h; Ket qua ban au s dung xi mang trong ieu tr bu xng; Moi tng quan lam sang Xquang giai phau benh trong chan oan cac bu xng. Trong Y hoc TP.Ho Ch Minh, So ac biet chuyen e Chan Thng Chnh Hnh, Phu ban so 4 Tap 1, 1997. Trng ai Hoc Y Dc TP.Ho Ch Minh, 71 79, 80 87.

12. Le Van Tho, Le Ch Dung: Bu xng ban tay: phan loai giai phau benh, ket qua ieu tr (nhan 42 t.h). Trong Y hoc TP.Ho Ch Minh, Chuyen e Y hoc C s, Tap 7 Phu ban cua so 1, 2003, Trng ai Hoc Y Dc TP.Ho Ch Minh, 33 40.

13. Le Van Tho: Bu sun lanh ban tay: Chan oan va ieu tr, Ket qua 40 trng hp. Trong Y hoc TP.Ho Ch Minh, Chuyen e: Chan Thng Chnh Hnh. Phu ban Tap 6 so 1 2002. Trng ai Hoc Y Dc TP.Ho Ch Minh, 185 190.

14. McVey MJ, Kettner NW: Pathologic fracture of metacarpal enchondroma: case study and differential diagnosis. J Manipulative Physiol Ther., 25(5), 340-344, 2002.

15. Mirra JM (1989): Intramedullary Cartilage and Chondroid producing Tumors. In Bone Tumors : Clinical, Radiologic and Pathologic Correlation, Lea & Febiger, Philadelphia, Chap 8 : pp 439483.

16. Miyawaki T, Kinoshita Y, Iizuka T: A case of Olliers disease of the hand. Ann Plast Surg., 38(1), 77-80, 1997.

17. Montero LM, Ikuta Y: Enchondroma in the hand retrospective study recurrence cases. J. Hand Surg., Vol.7, No.1, 7-10, 2002.

18. Noble J, Lamb DW: Enchondromata of bones of the hand, A review of 40 cases. Hand, 6(3), 275-284, 1974.

19. Pun W.K., Chow S.P., Luk K.D.K., Chan K.C., Ngai W.K., Croby C., and C.Ng.: A Prospective Study on 284 Digital Fractures of the Hand. J.Hand Surg.,Vo 14A, No.3 : 474-485, 1989.

20. Swanson A.B: Evaluation of Impairment of Function in the Hand. The Surgical Clinics of North America, W.B.Saunders Co., Philadelphia, Vol.44 -No.4 : 925-940, 1964.

21. Takigawa K: Chondroma of the bones of the hand, A Review of 110 cases. J Bone Joint Surg. Vol.53 A, No.8: 1591- 1600, 1971.

22. Tordai P, Hoglund M, Lugnegard H: Is the treatment of enchondroma in the hand by simple curettage a rewarding method? J Hand Surg.[Br], 15(3), 331-334, 1990.

23. Wulle C: On the treatment of enchondroma. J Hand Surg.[Br], 15(3): 320-330, 1990.