THOÁI HÓA KHỚP

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THOI HA KHP. ThS Hunh Thanh Hin. Mc tiu. Hiu c c ch bnh sinh ca bnh THK. Trnh by c nhng tn thng trong bnh THK. M t c nhng c im lm sng v cn lm sng ca bnh THK. Chn on c mt trng hp THK. M t cc th lm sng ca bnh THK. I CNG. - PowerPoint PPT Presentation

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  • THOI HA KHPThS Hunh Thanh Hin

  • Mc tiuHiu c c ch bnh sinh ca bnh THK.Trnh by c nhng tn thng trong bnh THK. M t c nhng c im lm sng v cn lm sng ca bnh THK. Chn on c mt trng hp THK.M t cc th lm sng ca bnh THK.

  • I CNG- L bnh l thng gp nht ngi > 50 tui. - c trng ca bnh l s thoi ha trung tm sn khp v hnh thnh xng mi.- THK c xem nh mt bnh c nh hng n ton b cu trc khp. - THK gp mi chng tc, dn tc, mi iu kin kh hu, a l v kinh t khc nhau. - Nam v n mc bnh ngang nhau.- T l thoi ha khp gi n cao hn nam, t l thoi ha khp hng nam cao hn n. - Tn sut bnh tng theo tui. - Ti Php: chim 28,6% tng sbnh nhn mc bnh xng khp. Vit nam, tlny khong 30- 35%.

  • PHN LOI

    Theo nguyn nhn, ngi ta chia 2 loi 1. THK nguyn pht- S lo ha: l nguyn nhn chnh, bnh xut hin mun thng ngi sau 60 tui, tn thng nhiu v tr, tin trin chm v khng nng.- Yu t di truyn: hm lng collagen v kh nng tng hp proteoglycan (PG) ca sn.- Yu t ni tit v chuyn ha: mn kinh, i tho ng, long xng.

  • 2. THK th pht- a phn l do nguyn nhn c gii. Nhng nguyn nhn ny lm thay i c tnh ca sn v lm h hi b mt khp.- Bnh gp mi la tui (thng di 40 tui), tn thng mt hay vi v tr, nng v tin trin nhanh.- Mt s nguyn nhn nh:+ Tin s chn thng+ Tin s phu thut: ct sn chm...+ Tin s bnh xng: bnh Paget hoc hoi t xng.+ Bnh huyt hc: bnh nhn Hemophilie c tin s trn mu cc khp ti pht nhiu ln.+ Cc d dng bm sinh v ri lon pht trin: lon sn v trt khp hng bm sinh, li ci...+ Bnh ni tit v ri lon chuyn ha: bnh to u chi, Cushing, Gout...

  • C CH BNH SINH (THK nguyn pht) 1. S gi i ca sn v xng: tng dn theo tui tc lm sn khp mt tnh n hi chu lc.2. Yu t c hc- Do nhng vi chn thng tch ly cu trc xng di sn khp mt tnh chu lc thoi ha sn.- S tng p lc ln khp t bo sn cng li, gii phng cc enzym tiu protein hy hoi cc cht c bn dn ti THK.

  • 3. Yu t sinh ha hc- Tn thng sm ca sn trong THK do gim thnh phn PGs, thnh phn collagen bnh thng.- Vai tr ca cc cytokin tin vim: IL1 v TNF- gy nn qu trnh d ha trong THK- Vai tr ca nitric ocid (NO): tham gia qu trnh d ha sn. Trong THK, sn tit nhiu NO hn bnh thng.4. Yu t di truyn- Hm lng collagen v kh nng tng hp PGs ca sn mang tnh di truyn. - Pht hin s a dng v hnh th ca gen collagen type 2 trong mt vi gia nh b THK sm.

  • TN THNG BNH HC TRONG THK

    1. S ph v cu trc ca sn: Rn nt v nhuyn ha lp b mt bo mn trung tm v lan rng b mt sn sn b mng v trc ra.2. Bin i xng di sn: x ha xng di sn, to nang v xng b dy ln do s ha ng.3. S pht trin nhanh phn ng ca xng mi v sn b mt khp: to nn hnh nh gai xng, c xng di sn.4. Nhng tn thng khc: vim mng hot dch, s teo c quanh khp v thoi ha xng bnh ch.

  • LM SNG* au khp: lin quan n vn ng, thng au m tng khi vn ng, thay i t th, gim au v m v khi ngh ngi.* Hn ch vn ng: cc ng tc nh bc ln hoc xung cu thang, ang ngi gh ng dy, ngi xm, i b lu lm xut hin cn au...* Bin dng khp: do mc cc gai xng, do lch trc khp hoc thot v mng hot dch.* Cc triu chng khc:- Ting lc khc khi vn ng khp- Du hiu ph r khp: cng khp bui sng khng qu 30 pht.- C th s thy cc chi xng quanh khp.- Teo c do t vn ng.- Trn dch khp: do phn ng vim th pht ca mng hot dch.- Thng khng c biu hin ton thn.

  • CN LM SNG1. X quang qui c: c 3 du hiu c bn- Hp khe khp: khe khng ng u, b khng u.- c xng di sn: gp phn u xng, trong phn xng c c mt s hc nh sng hn.- Mc gai xng: phn tip gip gia xng, sn v mng hot dch. C th c mt s mnh xng ri ra nm trong khp hay phn mm quanh khp.2. Siu m khp: c th pht hin c- Hp khe khp.- Gai xng.- Trn dch khp: thng ti cng trn trong, ngoi v trn xng bnh ch.- Mnh xng hoc sn t do trong khp: thng ti cng trn.- Dy bao hot dch.

  • 3. Chp ct lp vi tnh: pht hin tn thng sn khp, khng thy r tn thng mng hot dch.4. Chp cng hng t (MRI): - Quan st c khp trong khng gian 3 chiu.- Pht hin tn thng sn khp, xng di sn, dy chng v mng hot dch.Cc kt qu nh gi tn thng sn gia MRI v ni soi khp c s tng quan. Tuy nhin, ni soi khp vn l tiu chun vng chn on THK.

  • 5. Ni soi khp (NSK)- L tiu chun vng chn on THK.- L phng php quan st trc tip khp - NSK cn nh gi c mc canxi ha sn khp, phn tch tn thng phn xng di sn.- Sinh thit mng hot dch khi ni soi lm cc xt nghim sinh ha, t bo, min dch cho php chn on chnh xc hn cc tn thng bnh l trong khp.6. Cc xt nghim khc- Xt nghim mu v sinh ha mu: VS, CRP bnh thng, lng BC bnh thng, ch tng khi c phn ng vim th pht mng hot dch.- Dch khp: bnh thng hoc vim mc t trong cc t tin trin. Dch thng c mu vng trong, nht bnh thng hoc gim nh, < 1000 tb/mm3.

  • CHN ONTiu chun ACR 1991

  • 10 selected joints are the second and third distal interphalangeal joints, the second and third proximal interphalangeal joints and the first carpometacarpal joints (of both hands).

  • Chn on phn bit

    - Vim khp dng thp: th 1 khp ln, th nhiu khp.- Bnh ct sng huyt thanh m tnh: vim khp vy nn, vim ct sng dnh khp, bnh Reiter (vim khp, vim niu o, vim kt mc mt).- Vim khp vi tinh th: gout, gi gout.- Bnh khp lin quan n bnh l rut: vim lot i trng km vim khp gi c chn; bnh crohn: vim khp cng chu, vim ct sng hoc cc khp chi di kt hp vim lot i trng.

  • CC TH LM SNGThoi ha khp gi- N chim 80% trng hp.- Nguyn nhn+ S lo ha+ Cc d tt ca trc khp gi: khp gi quay ra ngoi, vo trong hay qu dui.+ Cc di chng ca bnh khp gi: chn thng, vi chn thng ngh nghip, di chng vim, chy mu khp.- Lm sng: au khp tng khi vn ng, cng khp bui sng < 30 pht, gim kh nng vn ng, c ting lc khc khi c ng, tng cm gic au xng, s thy xng.

  • Thoi ha khp hng- Nam mc bnh nhiu hn n, Chu u nhiu hn Chu .- THK hng th pht chim 50% trng hp, thng do:+ Lon sn v trt khp hng bm sinh.+ Hoi t v khun chm xng i+ Li ci bm sinh.+ Di chng chn thng, vi chn thng.+ Di chng vim.- Lm sng:* C nng+ au vng bn hoc vng trn mng, lan xung i, c khi ch au trc i v khp gi. au tng khi i li, ng lu, gim khi ngh ngi, c du hiu ph g khp.+ Hn ch vn ng: kh ngi xm, ln xe p,.. v sau i li khp khing, phi chng gy.* Thc th+ C cc im au mt trc khp v phn trn mng. o thy chn bnh ngn hn chn lnh.+ Hn ch vn ng dui, v sau c ng tc gp.* X quang: c hnh nh hp khe khp, c xng di sn v mc gai xng.

  • Thoi ha khp bn tay- Thng gp khp bn ngn xa, hoc khp bn ngn gn hoc khp bn ngn tay ci.- au t, hn ch vn ng khp.Gai xng gt- au vng gt chn c bit khi ng dy, khi t gt chn xung t.- X quang: hnh nh gai xng gt chn.

  • HNG IU TR1. Mc tiu- Gim au.- Duy tr v ci thin kh nng vn ng.- Hn ch v ngn nga bin dng khp.- Trnh tc dng ph ca thuc.- Ci thin cht lng cuc sng.

  • 2. iu tr ni khoa- Gio dc bnh nhn: gim cn, trnh cc t th xu gy lch trc khp.- Vt l tr liu- Nhit iu tr: chm nng, hng ngoi, siu m...- Thuc:* iu tr triu chng: gim au, NSAID,thuc bi ngoi da, corticosteroid ( ton thn v ti khp).* iu tr theo c ch bnh sinh: Glucosamin sulphat, Chondroitin sulphat, ch phm kt hp 2 loi .* Thuc c ch cytokin, thuc c ch ph hy sn, nhm Biphosphonat.* B sung cht nhy dch khp.

  • 3. Ngoi khoa- iu tr bng ni soi khp.- Phng php c xng chnh trc.- Cy t bo t thn- ghp sn.- Phng php vi gy.- Thay khp nhn to.

  • CU HI???

    + Bnh to u chi: tng hormon qu mc lm sn khp dy ln, mt tnh n hi chu lc.+ Bnh cushing v s dng corticosteroid ko di: corticosteroid c ch chc nng to ct bo gy cng cn gip th pht, kch thch hot ng hy ct bo v lm tng qu trnh hy xng di sn.+ Bnh Gout: tinh th urat lng ng trong dch khp.

    . S gim PGs gy ra nhng thay i sinh ha hc nh mt tnh chu lc ca sn, gim s n hi v tng tnh thm nc. Sau cu trc si collagen trong lp nn b ti ra v mt dn i do tng hot tnh ca enzym tiu protein metalloproteinase (MMPs).

    - L phng php quan st trc tip khp nn cho php nh gi chnh xc v mc , tnh trng, phm vi v nh khu c cc tn thng sn, mng hot dch, dy chng...nhng tn thng m khng pht hin c trn X quang thng thng.

    10 selected joints are the second and third distal interphalangeal joints, the second and third proximal interphalangeal joints and the first carpometacarpal joints (of both hands).