VT L TR LIU PHC HI CHC NNG THOI HA KH GI
VT L TR LIU PHC HI CHC NNG THOI HA KHP GIBS. CM B THC
NI DUNGS lc gii phu khp gi (articulatio genus)Nguyn nhn tn thng
khp giTriu chng hc thoi ha khp giThm khm khp giVt l tr liu phc hi
chc nng (PHCN) thoi ha khp gi.Tim khp gi.
GII PHUL khp phc hp gm ba khp Khp xng i v xng chy l hai khp li
cuKhp gia xng i v xng bnh ch l mt khp rng rc.Hot ng nh mt khp bn l
(ginglymus)
GII PHUDin khp xng i (Facies articulation):Li cu (condylus) u di
xng i: gm hai li cu trong (medialis) v ngoi (lateralis) khp vi hai
din khp u trn xng chy.Pha trc hai li cu dnh lin nhau to thnh m ca
rng rc hng ra trc gi l din bnh ch (facies patellaris). Pha sau hai
li cu tch xa nhau bi h gian li cu (fossa intercondylaris).
GII PHUDin khp u trn xng chy (facies articularis superior)u trn
xng chy cng loe rng thnh hai li cu ly xng i bng din lm hai mt khp
trn ca n, din ngoi rng v nng hn din trong.Gia hai din khp c li gian
li cu (emimentia intercondylaris), chia khong gia hai din khp thnh
din gian li cu trc v din gian li cu sau.
GII PHUSn chm (maniscus): c hai sn chm nm phn chu vi ca hai din
khp ca hai li cu xng chy, sn chm ngoi hnh ch O sn chm trong hnh ch
C, hai sn chm dnh vo li cu xng chy bi cc u tn trc v sau ca chng: cc
sng trc dnh vo din gian li cu sa. Hai b trc v sau ca sn chm c dnh
vi nhau bi dy chng ngang gi (Ligamentum transversum genus)Sn chm
ngoi dnh lng lo nn trt nh khi vn ng, sn chm trong dch chn nn c th b
bong khi vn ng mnh v t ngt.
GII PHUXng bnh ch (Patellaris)Hnh bnh chMt sau tip gip vi din
bnh ch ca u di xng i.
GII PHUPhng tin ni khp:Bao khp (Capsular): l mng x, bao quanh
khp, khng th tch ri cc dy chng xung quanh.+ Pha xng i: bm vo ng vin
un ln trn din rng rc, trn hai li cu v h gian li cu.+ Pha xng chy:
bm vo xung quanh hai li cu xng chy pha di hai din khp;+ Pha trc: bm
vo cc b ca xng bnh ch;+ gia: dnh vo sn chm nn chia lm hai tng. Tng
trn sn chm rng v tng di sn chm hp.
GII PHUBao hot dch (synovia): Ph mt trong bao x, rt phc tp:+ trn
bm vo xung quanh din khp xng i, di bm vo din khp xng chy, gia bm vo
sn chm, chia khp thnh hai tng;+ sau ph trc dy chng bt cho, tuy lch
gia nhng dy chng bt cho nm trong bao khp nhng li nm ngoi bao hot
dch.+ trc: Bao hot dch nh ln cao to thnh ti cng hot dch trn xng bnh
ch, gia gn c t u i v xng i.
GII PHUCc dy chng: khp gi c 5 h thng dy chng: Dy chng bn:+ Dy
chng bn chy (ligamentum collateral tibia): i t c trn li cu trong
xung di ra trc bm vo mt trong u trn xng chy.+ Dy chng bn mc
(ligamentum collateral fibular): i t c trn li cu ngoi xng i chch
xung di v ra sau bm vo chm xng mc.
GII PHUCc dy chng trc:- Dy chng bnh ch (ligamentum patellae)- Mc
hm bnh ch trong (retinaculum patellae mediale)- Mc hm bnh ch ngoi
(retinaculum patellae laterale)- Ngoi ra cn c gn c t u i, c may, c
cng mc i tng cng.
GII PHUCc dy chng sau:Dy chng khoeo cho (ligamentum popliteum
obliquum): l mt ch qut ngc ca gn c bn mc, i t trong ra ngoi, t di
ln trn ri bm vo li cu ngoi xng i.Dy chng khoeo cung (ligamentum
popliteum arcuatum) i t chm xng mc ta thnh hai b bm vo xng chy v
xng i to thnh mt vnh cung c c khoeo chui qua.
GII PHUCc dy chng bt cho trong h gian li cu (xng i):Dy chng cho
trc (ligamentum cruciatum anterius) i t mt trong li cu ngoi xng i
ti din gian li cu trc xng chy (hm xng chy khng trt ra trc)Dy chng
cho sau (ligamentum cruciatum posterius): i t mt ngoi li cu trong
xng i ti din gian li cu sau xng chy (hm xng chy khng trt ra
sau).Hai dy chng bt cho nhau hnh ch X, dy chng trc pha ngoi, dy
chng sau pha trong.
GII PHUCc dy chng sn chm:Dy chng ngang gi (ligamentum
transversum genus) ni ni hai b trc ca hai sn chm vi nhau;Dy chng
chm i trc (ligamentum meniscofemorale anterius) l mt si ca dy chng
bt cho trc, i t li cu ngoi ca xng i n bm vo sng trc ca sn chm
trong;Dy chng chm i sau (ligamentum meniscofemorale posterius) l mt
si ca dy chng bt cho trc, i t li cu ngoi xng i n bm vo sng trc ca
sn chm trong.
Nguyn nhn tn thng khp giChn thng: lao ng, giao thng, sinh hot,
th thao, thin tai, chin tranh, hnh hung, t t;Vim nhim: vim do nhim
khun, vim lao;Do thp: thp khp cp (thp tim)/ acute , vim khp dng thp
(rheumatoid), vim ct sng dnh khp (ankylosing spondylitis).Do bnh
chuyn ha: goutThoi ha khp (degeneration): ngi cao tui, n >
namVim xng khp (osteoarthritis), long xng (bone loss)
Nguyn nhn, c ch bnh sinh thoi ha khp gin nay cn nhiu tranh ci, c
hai l thuyt chnh:Thuyt c hc: di nh hng ca c hc, vi tn thng xng do
suy yu collagen dn n vic h hng cc proteoglycanThuyt t bo: t bo b
cng li do tng p lc, gii phng cc enzym tiu protein, ezym ny hy hoi
dn cc cht cn bn.Nhng thay i ca sn khp v phn xng di sn trong thoi ha
khp: sn khp chnh l phn chnh b tn thng. Khi b thoi ha sn s chuyn
sang mu vng nht, mt tnh n hi, mng, kh v nt n, mt dn sn lm tr xng di
sn, phn ra xng v sn c xng tn to (gai xng).
Nguyn nhn, c ch bnh sinh thoi ha khp giC ch ca qu trnh vim trong
thoi ha khp: song song vi thoi ha l hin tng vim din bin thnh tng t,
biu hin au v gim chc nng vn ng, tng s lng t bo trong dch khp km
theo vim mng hot dch kn o v t chc hc. Nguyn nhn c th do phn ng ca
mng hot dch vi cc sn phm thoi ha sn, cc mnh sn hoc xng b bong raC
ch au trong thoi ha khp gi: au l triu chng buc bnh nhn n vin, do
trong sn khng c thn kinh do au c th do c ch nh sau:+ Vim mng hot
dch phn ng
Nguyn nhn, c ch bnh sinh thoi ha khp gi+ Xng di sn tn thng rn nt
nh gy kch thch to cm gic au;+ Gai xng ti cc v tr t gy ko cng u mt
thn kinh mng xng;+ Dy chng b co ko do trc khp b tn thng, mt n nh v
bn thn tnh trng lo ha ca dy chng gy dn giy chng, l nguyn nhn mt n
nh trc khp, dn n tnh trng thoi ha khp trm trng hn. + Vim bao khp,
bao khp b cng phng do ph n quanh khp;+ Cc c b co ko, nguyn nhn tng
t tn thng ca dy chng.
Triu chng lm sngTriu chng c nng: au ti khp, au m , tng khi vn
ng, gim khi ngh ngi, au tng t v c th tm ht sau ti pht nhiu ln;Du
hiu ph r khp: l du hiu cng khp bui sng ko di chng 15-30p, cng khp
khi ngh ngi v phi vn ng mt lc mi tr li bnh thng.Ting ng ti khp xut
hin khi vn ng, c ting lc cc i khi c th nghe c.Hn ch vn ng khp
Triu chng thc th (khm khp gi)Nhn: sng, , teo c quanh khpS: nng
hay khngVn ng khp tm ting kuo tm vn ng: o tm vn ng ch ng v th ng
theo phng php zero; chu vi bp c trn v di khp.Du hiu bp bnh xng bnh
ch (patella floating)Du hiu ngn ko (drawer sign)Du hiu lachman,
McMurray test, Pivot shift test.Du hiu lng lo khp / rung lc
(impingement).Ht Herberden u xa ngn tay.
Ht Herberden
Ht Herberden
Du hiu rt ngn ko, c gi tr chn on t dy chng cho (Ant/Post
Cruciate Ligament)
Du hiu rt ngn ko c gi tr chn on t dy chng cho (Ant/Post Cruciate
Ligament)
Du hiu Lachman c gi tr chn on t dy chng cho trc (Anterior
Cruciate Ligament)
McMurray test c gi tr chn on bong sn chm (meniscal lession)
McMurray test c gi tr chn on bong sn chm (for meniscal
lession)
Pivot shift test c gi tr chn on t dy chng cho trc (Anterior
Cruciate Ligament)
Pivot shift test c gi tr chn on t dy chng cho trc (Anterior
Cruciate Ligament)
Cn lm sngXt nghim mu: khng c hi chng vim, tc mu lng, CRP, bnh
thngDch khp: khng c hi chng vim, ngho t bo; kt qu so snh vi vim khp
gi do nhim khun:Lng dch khp t (di 20ml)/ # > 60mlMu sc: khng mu/
vng nht/ # vng chanh, sm trong: trong/ # c nht: bnh thng / # gim
nhtS lng t bo: Di 2000/mm3 / / # trn 2000mm3
Cn lm sngChp xquang: du hiu hp khe khp, c xng di sn, xp cc din
di sn, hnh nh tn to xng (chi xng, gai xng). C th gp hnh nh hy khp
(him).Du hiu chp MRI: nhn thy tn thng c phn xng, dy chng, bao khp,
trn dch.Siu m: nhn thy hnh nh tn thn cch dy chng trc, bn, sau, trn
dch, c th bit c tnh trng ng mch khoeoNi soi khp
Chn on Chn on l thoi ha khp gi theo tiu chun ca hi khp hc hoa k
(American College of Rheumatology/ACR 1991).* Lm sng, Xquang v xt
nghim:(1) au khp gi,(2) C gai xng ra xng trn phim Xquang thng
quy(3) Dch khp l dch thoi ha(4) Tui t 40 tr ln(5) Cng khp di 30p(6)
C ting lc cc khi c ngChn on xc nh khi c yu t 1,2 hoc 3,5,6 hoc
1,4,5,6. Tiu chun ny t nhy < 94% v c hiu 88%;
Chn on* Lm sng n thun:(1) au khp gi,(2) C ting lc cc khi c ng(3)
Cng khp di 30p(4) Tui t 38 tr ln(5) S thy ph i xngChn on xc nh khi
c yu t 1,2,3,4 hoc 1,2,5 hoc 1,4,5.Giai on bnh: giai on II v III
theo phn loi ca Kellgren v Lawrence .
Chn on phn bitVim khp dng thp th mt khp: xquang c hnh bo mn v mt
cht khong u xng; Huyt thanh v dch khp c hi chng vim sinh hc; Yu t
thp trong huyt thanh dng tnh. Ni soi sinh thit mng hot dch c th chn
on chnh xc.Vim khp dng thp th nhiu khp: tn thng nhiu khp ch yu cc
khp nh, sng phn mu nhiu hn, i xng, cng khp bui sng, gp n tui trung
nin, bnh ko di trn 2 thng. Xt nghim mu c tc mu lng tng, yu t thp
dng tnh, ni soi sinh thit mng hot dch chn on chnh xc.
iu tr ni khoaNhm thuc gim au: hiu qu, t c vi d dy v thn hn thuc
chng vim khng steroid. Cc s dng theo s bc thang ca WHO.Thuc chng
vim khng steroid (NSAIDs): trong tho ha khp c hin tng vim mng hot
dch km theo - l nguyn nhn gy au, iu ny gii thch tc dng ca NSAIDs i
vi triu chng au. Mt khc, thuc NSAIDs c c tc dng gim au ni ring, vic
la chn nn theo nguyn tc sau: - Trnh cc thuc NSAIDs c th lm tng qu
trnh thoi ha nh Idomethacine (cha khng nh).
iu tr ni khoaCc thuc NSAIDs nn la chn: Voltarel ung hoc tim bp;
thuc ny tc dng khng tt i vi ng tiu ha, khng nn dng qu 5 ngy, phi kt
hp cc thuc gim tit dch v v bng nim mc, cn theo di v nhanh chng pht
hin tc dng ph ca thuc.Thuc NSAIDs c ch chn lc trn COX-2 nh
MobicMisoprostol (Cytolex ) l ng ng ca prostaglandine E1
200microgram, liu 4 vin mi ngy chia 4 ln.
iu tr ni khoaThuc Corticoid: Dng ng ton thn (ung/tim bp/tim tnh
mch) l chng ch nh;Dng ni khp: rt hiu qu i vi cc du hiu c nng ca
thoi ha khp giai on sm. Tuy nhin ch c dng tim khng qu hai t mt nm,
mi ln tim cch nhau t 2 n 3 thng. Khi tim phi m bo v trng tuyt i;+
Hydrocortisone actate: mi t 2-3 mi tim cch nhau 5-7ngy, khng tim qu
4 mi mi t.+ Cc ch phm c tc dng ko di (Diprospan, Depomedrol): mi t
1-2 mi cch nhau 6-8 tun
iu tr ni khoaThuc chng thoi ha:Thuc chng thoi ha tc dng chm
(SySADOA/Symtom Slow Acting Drugs for Osteoarthritis) l nhm thuc iu
tr mi, hiu qu c c sau mt thng v duy tr c sau khi ngng iu tr, liu
trnh iu tr t 1-2 thng. Dung np thuc tt, hu nh khng c tc dng ph.Cc
ch phm:(1) Glucosamin Sulfat (Viartril S ): glucosamin sulfat l cht
cn thit cho qu trnh sinh tng hp v kch thch t bo sn sn xut
proteoglycan c cu trc bnh thng.
iu tr ni khoaThuc chng thoi ha tc dng chm (tip):Tng tng hp
proteoglycan s lm tng cng ca m sn, do vy trnh c tn thng sn do chn
thng c hc; glucosamin sulfat c kh nng lm gim ng k s ph hy sn nh tnh
cht kch thch cc hot ng ng ha ca sn v c ch cc enzym hy sn khp nh
collagenese v phospholipase A2 (c ch sinh ra cc gc superoxid hy t
bo), thuc ny cn c ch interleukin.
iu tr ni khoaThuc chng thoi ha tc dng chm (tip):Liu dng:
1-1,5gram mi ngy, ch phm dng gi bt hoc vin nhng ung trc ba n, dng
ng tim bpTc dng khng mong mun: s t bnh nhn ban u tiu chy hoc phn
nt, sau quen v dn.(2) Diacereine (Antrodar ), ART 50.: L mt phn t
thuc nhm anthraquinon, l dng tin cht ca Rhein trc khi diacetyl ha
(Diacereine khi b diacetyl s thnh Rhenin), thuc c ch IL1 nn ngt c
vng xon bnh l gy ra bi IL1. Kch thch yu t pht trin (TGF-Beta/
Transformin Growth Factor) kch thch t bo sn tng tng hp collagen typ
2, proteoglycan v acide hyalunoric.
iu tr ni khoaCh phm : vin nhng 50mg, ung 100mg/24h mi, ko di t
nht 3 thng.Tc dng khng mong mun l tiu chy nh v i mu nc tiu (mu ca
thuc). (3) Piascledin , l thnh phn khng x phng ha ca qu b (avocat)
v u nnh (Soja)Ch phm vin nhng 0,3gLiu 0,3g mi ngy, duy tr t nht hai
thng.
iu tr ni khoa(4) Chondroitin sulfat (Structum,Chondrosulf): c ch
mt s enzym tiu sn, nht l enzym metalloproteases. Liu: 1gram/ ngy(5)
Dch nhy (Hyalunoric acide): Go-on, Hyalgan, Hyruan Plus, Synvisc,
Orthto Visc, dng tim ni khp, cung cp cht nhy:Loi nht tuyt i # 300
centipoise: Hyalgan10mg, Ostenil10mg, Hyruan Plus, Loi c nht rt
cao: Orthto Visc15mg- #55.000, Synvisc 8mg- #56.000 centipoise.
iu tr ni khoaCch dng: thuc c nht thp nn tim 5 mi ni khp mi liu
trnh, cc thuc nht cao nn tim ba mi; tim mi mi 1ng/ 1tun;Hiu qu: gim
au v ci thin vn ng r ngay t mi tim u.Hin nay cc thuc ny cn c dng
trong cng khp vai
Vt l tr liu PHCN Giai on cp: au, sng v hn ch vn ng:Khng tp luyn,
ngh ngi v duy tr sinh hot bnh thng, hn ch i li trnh lm tn thng khp
trm trng hn.Hng ngoi: nhit kh nng, lm sng n thm, khng dng;B nn:
nhit t nng, lm sng n thm, khng dng;Sng ngn vi sng: nhit su, lm sng
n thm, khng dng.Siu m: to vi mt xa, c th lm sng n thm, khng
dng.
Vt l tr liu PHCNGiai on cp: Trm lnh (cryotherapy): tc dng co
mch, gim vim, gim ph n phn mm quanh khp, c th dng.in xung dng giao
thoa 4 cc t cho nhau qua gi c tc dng gim au, 15 20 pht/ ln, c th
dng.in dn thuc: s dng novocain v nc mui sinh l (hoc Iodua Kali) in
cc m, c tc dng gim au, thi gian mi ln khng qu 10 pht, c th 2ln/ngy.
Hoc dng hydrocortison in cc dng v nc mui sinh l (hoc Iodua Kali) in
cc m, c tc dng chng vim ti ch gim ph n nn gim au.
Vt l tr liu PHCNGiai on cp: T trng: cha c kinh nghim; c loi khng
nhit v loi c nhit v c rung; c th dng loi t trng khng c nhit, loi
nhit rung khng nn dng;Sng xung kch (sng kch sc): to lc tc ng mnh, c
th gy au v lm tn thng thm cc m trong giai on vim, khng nn dng; nhn
chung t dng trong khp gi.Laser cng xut thp: tc dng sinh hc l chnh,
chiu ngoi, chm (chiu vo huyt quanh khp), hoc ni mch, c th dng, hiu
qu cha c chng minh bng thc chng (cha c nghin cu thc s labo, ch yu
cc nghin cu ca Trung quc)
Vt l tr liu PHCNGiai on mn: ht au, ht sng n, Duy tr sinh hot, vn
ng khng chu trng lc hoc i li tng dn,S dng hng ngoi, b nn c tc dng
lm dn mch, tng dinh dng cho phn mm quanh khp, lm do dai gip khp hot
ng linh hot hn.Sng ngn, vi sng, siu m iu tr c th s dng c, c tc dng
tng dinh dng t chc, gim qu trnh tn thng v tng ti to. Khng dng sng
xung kch.
Vt l tr liu PHCNGiai on mn:Chm cu: khng c kinh nghim, nu kim
khng v trng chm vo khp c th gy vim khp m.Tp luyn: tp khng chu trng
lc, tp chu trng lc, tp tng dn theo kh nng chu ng, khng nn vn ng thi
qu v c th lm tng ti din cc t cp, cn c chin lc bo v khp lu di.Bng
thun b m hoc cc loi np mm h tr cho khp gi c th dng khi i li nhng
phi ch gi v sinh v phng trnh tn thng da.
H tr khp
H tr khp
Tim corticoid vo khp
Tim dch nhy vo khp c siu m dn ng chnh xc cn c siu m dn ng, s dng
u d Line tn s..Hz, nguyn l t u d v kim chc nh sau
Tim dch nhy vo khp c siu m dn ng
Tim dch nhy vo khp c siu m dn ng
Phu thut thay khpPhu thut thay khp gi t c p dng hn cc khp khc v
phn mm xung quanh t, dn n khp yu v gim bn;Bo v khp gi l c bn, ch
thay khi mt kh nng i li, tui th khp gi ty loi, c loi c bn 15 nm.Tn
km v nhiu tai bin, sau m vn cn PHCN
Cu hi ?
