{"id":3143,"date":"2023-04-09T23:59:24","date_gmt":"2023-04-09T16:59:24","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=3143"},"modified":"2023-04-10T11:06:43","modified_gmt":"2023-04-10T04:06:43","slug":"ky-thuat-cat-xuong-doc-lap-trong-phau-thuat-thay-khop-goi","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/09\/ky-thuat-cat-xuong-doc-lap-trong-phau-thuat-thay-khop-goi\/","title":{"rendered":"K\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp trong ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i"},"content":{"rendered":"

Ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i to\u00e0n ph\u1ea7n\u00a0 l\u00e0 ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb tri\u1ec7t \u0111\u1ec3 v\u00e0 hi\u1ec7u qu\u1ea3 b\u1ec7nh l\u00fd tho\u00e1i ho\u00e1 kh\u1edbp g\u1ed1i<\/a> m\u1ee9c \u0111\u1ed9 n\u1eb7ng. K\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp l\u00e0 1 trong 2 k\u1ef9 thu\u1eadt c\u01a1 b\u1ea3n c\u1ee7a ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i to\u00e0n ph\u1ea7n. B\u00e0i vi\u1ebft sau \u0111\u00e2y s\u1ebd tr\u00ecnh b\u00e0y t\u1ed5ng quan v\u1ec1 k\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp v\u00e0 nh\u1eefng \u01b0u, nh\u01b0\u1ee3c \u0111i\u1ec3m c\u1ee7a k\u1ef9 thu\u1eadt n\u00e0y.<\/strong><\/p>\n

T\u00e1c gi\u1ea3: PGS. TS. Tr\u1ea7n Trung D\u0169ng<\/p>\n

1. K\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp trong ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i<\/h2>\n

K\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp (measure resection technique) \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng ph\u1ed5 bi\u1ebfn h\u01a1n, do Preeman- Insall \u0111\u1ec1 x\u01b0\u1edbng. Quy tr\u00ecnh bao g\u1ed3m c\u1eaft x\u01b0\u01a1ng \u0111\u1ea7u d\u01b0\u1edbi x\u01b0\u01a1ng \u0111\u00f9i v\u00e0 \u0111\u1ea7u tr\u00ean x\u01b0\u01a1ng ch\u00e0y \u0111\u1ed9c l\u1eadp nhau, theo c\u00e1c d\u1ee5ng c\u1ee5 \u0111\u1ecbnh v\u1ecb d\u1ef1a tr\u00ean c\u00e1c m\u1ed1c x\u01b0\u01a1ng s\u1eb5n c\u00f3.<\/p>\n

Ph\u1ea7n \u0111\u1ea7u tr\u00ean x\u01b0\u01a1ng ch\u00e0y \u0111\u01b0\u1ee3c c\u1eaft nh\u01b0 th\u01b0\u1eddng quy – m\u1eb7t ph\u1eb3ng tr\u00e1n vu\u00f4ng g\u00f3c v\u1edbi tr\u1ee5c x\u01b0\u01a1ng ch\u00e0y, c\u00f3 th\u1ec3 c\u1eaft ph\u1eb3ng ho\u1eb7c nghi\u00eang sau 3\u00b0 – 6\u00b0 tu\u1ef3 theo thi\u1ebft k\u1ebf c\u1ee7a t\u1eebng lo\u1ea1i kh\u1edbp g\u1ed1i nh\u00e2n t\u1ea1o.<\/p>\n

Ph\u1ea7n \u0111\u1ea7u d\u01b0\u1edbi x\u01b0\u01a1ng \u0111\u00f9i bao g\u1ed3m c\u00e1c l\u00e1t c\u1eaft \u0111\u1ea7u xa, l\u00e1t c\u1eaft b\u1edd tr\u01b0\u1edbc – sau, l\u00e1t c\u1eaft ch\u00e9o. Trong \u0111\u00f3 l\u00e1t c\u1eaft \u0111\u1ea7u xa x\u01b0\u01a1ng \u0111\u00f9i y\u00eau c\u1ea7u ph\u1ea3i vu\u00f4ng g\u00f3c v\u1edbi tr\u1ee5c c\u01a1 h\u1ecdc c\u1ee7a x\u01b0\u01a1ng \u0111\u00f9i, t\u1ee9c l\u00e0 t\u1ea1o v\u1edbi tr\u1ee5c gi\u1ea3i ph\u1eabu x\u01b0\u01a1ng \u0111\u00f9i g\u00f3c nghi\u00eang ngo\u00e0i (g\u00f3c valgus) 5\u00b0 – 7\u00b0. L\u00e1t c\u1eaft \u0111\u1ea7u xa c\u00f9ng v\u1edbi l\u00e1t c\u1eaft m\u00e2m ch\u00e0y quy\u1ebft \u0111\u1ecbnh \u0111\u1ebfn kho\u1ea3ng du\u1ed7i. L\u00e1t c\u1eaft b\u1edd tr\u01b0\u1edbc – sau song song v\u1edbi nhau, quy\u1ebft \u0111\u1ecbnh kho\u1ea3ng g\u1ea5p v\u00e0 \u0111\u1ed9 xoay ngo\u00e0i c\u1ee7a ph\u1ea7n \u0111\u00f9i. \u0110\u1ed9 xoay ngo\u00e0i c\u1ee7a ph\u1ea7n \u0111\u00f9i d\u1ef1a v\u00e0o tr\u1ee5c xuy\u00ean m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u \u0111\u00f9i ph\u1eabu thu\u1eadt (sTEA- surgical TransEpicondylar axis)[1],[2] ho\u1eb7c tr\u1ee5c tr\u01b0\u1edbc sau l\u1ed3i c\u1ea7u \u0111\u00f9i (\u0111\u01b0\u1eddng Whiteside, APA \u2013 AnteroPosterior axis) [3],[4] ho\u1eb7c tr\u1ee5c n\u1ed1i b\u1edd sau hai l\u1ed3i c\u1ea7u \u0111\u00f9i (PCA PosteiorCondylar axis) [5],[6] tu\u1ef3 theo l\u1ef1a ch\u1ecdn c\u1ee7a ph\u1eabu thu\u1eadt vi\u00ean v\u00e0 tr\u1ee3 c\u1ee5 \u0111\u1ecbnh v\u1ecb; trong \u0111\u00f3 th\u01b0\u1eddng d\u1ef1a v\u00e0o tr\u1ee5c PCA \u0111\u1ec3 thi\u1ebft l\u1eadp g\u00f3c xoay ngo\u00e0i v\u00ec d\u1ec5 x\u00e1c \u0111\u1ecbnh trong qu\u00e1 tr\u00ecnh ph\u1eabu thu\u1eadt.<\/p>\n

C\u00e1c m\u1ed1c x\u01b0\u01a1ng nh\u01b0 tr\u1ee5c sTEA, PCA, APA \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ed9 xoay c\u1ee7a ph\u1ea7n \u0111\u00f9i trong k\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng chu\u1ea9n. Kh\u00f4ng gi\u1ed1ng nh\u01b0 k\u1ef9 thu\u1eadt c\u00e2n b\u1eb1ng kho\u1ea3ng, c\u00e1c l\u00e1t c\u1eaft x\u01b0\u01a1ng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n \u0111\u1ed9c l\u1eadp v\u1edbi vi\u1ec7c c\u00e2n b\u1eb1ng ph\u1ea7n m\u1ec1m. Vi\u1ec7c s\u1eed d\u1ee5ng tr\u1ee5c sTEA, PCA hay APA \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ed9 xoay ngo\u00e0i cho ph\u1ea7n \u0111\u00f9i \u0111\u1ec1u c\u00f3 nh\u1eefng \u01b0u v\u00e0 nh\u01b0\u1ee3c \u0111i\u1ec3m ri\u00eang<\/p>\n

2. C\u00e1c m\u1ed1c x\u01b0\u01a1ng s\u1eed d\u1ee5ng trong k\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp (Ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i)<\/h2>\n

2.1. Tr\u1ee5c li\u00ean l\u1ed3i c\u1ea7u \u0111\u00f9i (Transepicondylar Axis – TEA)<\/h3>\n

Tr\u1ee5c li\u00ean m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u \u0111\u00f9i l\u00e0 \u0111\u01b0\u1eddng n\u1ed1i m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u ngo\u00e0i v\u1edbi m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u trong (tr\u1ee5c li\u00ean l\u1ed3i c\u1ea7u l\u00e2m s\u00e0ng, clinical Transepicondylar Axis – cTEA), ho\u1eb7c v\u1edbi r\u00e3nh khuy\u1ebft c\u1ee7a m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u trong (tr\u1ee5c li\u00ean l\u1ed3i c\u1ea7u ph\u1eabu thu\u1eadt, surgical Transepicondylar Axis – sTEA)[1],[7]. Tr\u1ee5c li\u00ean l\u1ed3i c\u1ea7u \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 l\u00e0 ph\u1ea3n \u00e1nh g\u1ea7n ch\u00ednh x\u00e1c nh\u1ea5t tr\u1ee5c g\u1ea5p – du\u1ed7i c\u1ee7a kh\u1edbp g\u1ed1i v\u00e0 l\u00e0 \u0111i\u1ec3m b\u00e1m nguy\u00ean u\u1ef7 c\u1ee7a h\u1ec7 th\u1ed1ng d\u00e2y ch\u1eb1ng b\u00ean[7]. Theo Berger v\u00e0 c\u1ed9ng s\u1ef1[1], tr\u1ee5c sTEA \u0111\u01b0\u1ee3c \u0111\u00f9ng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ed9 xoay ngo\u00e0i ch\u00ednh x\u00e1c nh\u1ea5t c\u1ee7a ph\u1ea7n \u0111\u00f9i. R\u00e3nh tr\u01b0\u1ee3t c\u1ee7a kh\u1edbp ch\u00e8 – \u0111\u00f9i v\u00e0 \u0111\u1ed9ng h\u1ecdc c\u1ee7a kh\u1edbp \u0111\u00f9i – ch\u00e0y s\u1ebd ch\u00ednh x\u00e1c h\u01a1n khi \u0111\u1eb7t ph\u1ea7n l\u1ed3i c\u1ea7u \u0111\u00f9i nh\u00e2n t\u1ea1o song song v\u1edbi tr\u1ee5c sTEA[8],[9],[10],[11]. Theo nghi\u00ean c\u1ee9u c\u1ee7a Insall v\u00e0 c\u1ed9ng s\u1ef1 [11] v\u1ec1 \u0111\u1ed9ng h\u1ecdc kh\u1edbp g\u1ed1i, t\u00ecnh tr\u1ea1ng lift-off (l\u1ed3i c\u1ea7u \u0111\u00f9i b\u1ecb ch\u00eanh l\u00ean cao) \u1edf m\u1eb7t ph\u1eb3ng Coronal \u00edt g\u1eb7p h\u01a1n \u0111\u00e1ng k\u1ec3 khi ph\u1ea7n LC\u0110 nh\u00e2n t\u1ea1o \u0111\u01b0\u1ee3c \u0111\u1eb7t song song v\u1edbi tr\u1ee5c TEA. Nghi\u00ean c\u1ee9u c\u1ee7a Olcott v\u00e0 Scott [10] ch\u1ec9 ra r\u1eb1ng \u0111\u1eb7t tr\u1ee5c ngang kh\u1edbp g\u1ed1i song song v\u1edbi sTEA gi\u00fap \u0111\u1ea1t \u0111\u01b0\u1ee3c kho\u1ea3ng g\u1ea5p c\u00e2n x\u1ee9ng t\u1ed1t nh\u1ea5t (90% s\u1eed d\u1ee5ng sTEA, 83% s\u1eed d\u1ee5ng APA, v\u00e0 70% s\u1eed d\u1ee5ng PCA). Ch\u00ednh v\u00ec th\u1ebf sTEA l\u00e0 \u0111\u01b0\u1eddng tham chi\u1ebfu trong thay l\u1ea1i kh\u1edbp g\u1ed1i to\u00e0n ph\u1ea7n v\u00e0 trong ph\u1eabu thu\u1eadt TKGTP l\u1ea7n \u0111\u1ea7u trong khi ph\u1ea7n sau l\u1ed3i c\u1ea7u b\u1ecb m\u00f2n ho\u1eb7c thi\u1ec3u s\u1ea3n.<\/p>\n

Tuy nhi\u00ean, vi\u1ec7c x\u00e1c \u0111\u1ecbnh ch\u00ednh x\u00e1c tr\u1ee5c n\u00e0y trong ph\u1eabu thu\u1eadt l\u00e0 r\u1ea5t kh\u00f3 kh\u0103n, g\u00e2y nhi\u1ec1u tr\u1edf ng\u1ea1i cho c\u00e1c ph\u1eabu thu\u1eadt vi\u00ean, do b\u1ecb c\u00e1c d\u00e2y ch\u1eb1ng v\u00e0 kh\u1ed1i c\u01a1 che ph\u1ee7 xung quanh [2],[12],[13],[14]. Jerosch v\u00e0 c\u1ed9ng s\u1ef1 [13] so s\u00e1nh s\u1ef1 kh\u00e1c nhau khi \u0111\u00e1nh d\u1ea5u v\u1ecb tr\u00ed c\u1ee7a m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u d\u1ef1a v\u00e0o kinh nghi\u1ec7m c\u1ee7a c\u00e1c ph\u1eabu thu\u1eadt vi\u00ean. T\u00e1c gi\u1ea3 nh\u1eadn th\u1ea5y r\u1eb1ng s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa c\u00e1c PTV khi x\u00e1c \u0111\u1ecbnh m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u trong l\u00ean t\u1edbi 22,3mm v\u00e0 l\u1ed3i c\u1ea7u ngo\u00e0i l\u00e0 13,8mm. Trong 74 tr\u01b0\u1eddng h\u1ee3p kh\u1edbp g\u1ed1i to\u00e0n ph\u1ea7n \u0111\u01b0\u1ee3c thay, Kinzel v\u00e0 c\u1ed9ng s\u1ef1 [14] nghi\u00ean c\u1ee9u m\u1ee9c \u0111\u1ed9 ch\u00ednh x\u00e1c c\u1ee7a vi\u1ec7c x\u00e1c \u0111\u1ecbnh c\u00e1c m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u \u0111\u00f9i. Khi ph\u00e2n t\u00edch qua phim ch\u1ee5p C\u1eaft l\u1edbp vi t\u00ednh (CLVT) sau m\u1ed5, c\u00e1c m\u1ecfm tr\u00ean LC\u0110 \u0111\u1ea1t \u0111\u1ed9 ch\u00ednh x\u00e1c trong kho\u1ea3ng \u00b1 3\u00b0 ch\u1ec9 \u1edf 75% c\u00e1c tr\u01b0\u1eddng h\u1ee3p. C\u00e1c t\u00e1c gi\u1ea3 l\u01b0u \u00fd r\u1eb1ng, c\u00f3 m\u1ed9t kho\u1ea3ng sai s\u1ed1 kh\u00e1 r\u1ed9ng (t\u1eeb 6\u00b0 xoay ngo\u00e0i \u0111\u1ebfn 11\u00b0 xoay trong) v\u00e0 k\u1ebft lu\u1eadn r\u1eb1ng vi\u1ec7c x\u00e1c \u0111\u1ecbnh tr\u1ee5c TEA trong m\u1ed5 \u0111\u1ec3 \u0111\u1eb7t \u0111\u1ed9 xoay cho ph\u1ea7n LC\u0110 nh\u00e2n t\u1ea1o s\u1ebd d\u1ec5 d\u1eabn \u0111\u1ebfn sai s\u00f3t. V\u00e0 khi tr\u1ee5c TEA \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ed9 xoay cho LC\u0110 th\u00ec c\u00f3 t\u1edbi 56% s\u1ed1 tr\u01b0\u1eddng h\u1ee3p sai l\u1ec7ch l\u1edbn h\u01a1n 5\u00b0, theo Yau v\u00e0 c\u1ed9ng s\u1ef1 [15]. Yau c\u0169ng l\u01b0u \u00fd r\u1eb1ng kho\u1ea3ng sai s\u1ed1 c\u1ee7a vi\u1ec7c x\u00e1c \u0111\u1ecbnh c\u00e1c m\u1ecfm tr\u00ean LC\u0110 trong m\u1ed5 l\u00ean t\u1edbi 28\u00b0 (11\u00b0 xoay ngo\u00e0i v\u00e0 17\u00b0 xoay trong). M\u1ed9t nghi\u00ean c\u1ee9u c\u1ee7a Siston v\u00e0 c\u1ed9ng s\u1ef1 tr\u00ean x\u00e1c ch\u1ebft, 11 ph\u1eabu thu\u1eadt vi\u00ean x\u00e1c \u0111\u1ecbnh c\u00e1c m\u1ed1c x\u01b0\u01a1ng d\u1ef1a v\u00e0o kinh nghi\u1ec7m th\u00ec xu h\u01b0\u1edbng th\u01b0\u1eddng b\u1ecb xoay ngo\u00e0i ph\u1ea7n \u0111\u00f9i qu\u00e1 m\u1ee9c so v\u1edbi tr\u1ee5c TEA chu\u1ea9n \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh d\u1ef1a tr\u00ean h\u00ecnh \u1ea3nh c\u1ee7a h\u1ec7 th\u1ed1ng \u0111\u1ecbnh v\u1ecb m\u00e1y t\u00ednh Navigation. Theo Nobuyuki Yoshino v\u00e0 Tiezheng Sun, ch\u1ec9 x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c tr\u1ee5c sTEA tr\u00ean 80% phim ch\u1ee5p CHT, 20% c\u00f2n l\u1ea1i l\u00e0 kh\u00f4ng x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c, b\u1ec7nh nh\u00e2n c\u00e0ng t\u1ed5n th\u01b0\u01a1ng x\u01b0\u01a1ng n\u1eb7ng th\u00ec tr\u00ean l\u00e2m s\u00e0ng c\u00e0ng kh\u00f3 x\u00e1c \u0111\u1ecbnh tr\u1ee5c n\u00e0y [6],[7].V\u00ec v\u1eady, vi\u1ec7c x\u00e1c \u0111\u1ecbnh tr\u1ee5c sTEA gi\u00e1n ti\u1ebfp qua m\u1ed9t tr\u1ee5c gi\u1ea3i ph\u1eabu kh\u00e1c v\u00e0 tr\u1ee5c n\u00e0y l\u1ea1i d\u1ec5 x\u00e1c \u0111\u1ecbnh trong ph\u1eabu thu\u1eadt l\u00e0 m\u1ed9t vi\u1ec7c l\u00e0m h\u1ebft s\u1ee9c c\u1ea7n thi\u1ebft.<\/p>\n

2.2. Tr\u1ee5c tr\u01b0\u1edbc – sau l\u1ed3i c\u1ea7u \u0111\u00f9i (AnteroPosterior Axis – APA)<\/h3>\n

Tr\u1ee5c tr\u01b0\u1edbc – sau l\u1ed3i c\u1ea7u \u0111\u00f9i l\u00e0 \u0111\u01b0\u1eddng n\u1ed1i \u0111i\u1ec3m th\u1ea5p nh\u1ea5t c\u1ee7a h\u00f5m r\u00f2ng r\u1ecdc \u1edf ph\u00eda tr\u01b0\u1edbc v\u1edbi \u0111i\u1ec3m cao nh\u1ea5t c\u1ee7a m\u00e1i l\u1ed3i c\u1ea7u \u1edf ph\u00eda sau. N\u00f3 ph\u1ee5 thu\u1ed9c v\u00e0o gi\u1ea3i ph\u1eabu b\u00ecnh th\u01b0\u1eddng c\u1ee7a h\u00f5m r\u00f2ng r\u1ecdc v\u00e0 m\u00e1i l\u1ed3i c\u1ea7u \u1edf l\u1ed3i c\u1ea7u x\u01b0\u01a1ng \u0111\u00f9i[16].<\/p>\n

\"hinh-5.1-cac-truc-giai-phau-xuong-dui\"
H\u00ecnh 5.1. C\u00e1c tr\u1ee5c gi\u1ea3i ph\u1eabu x\u01b0\u01a1ng \u0111\u00f9i<\/figcaption><\/figure>\n

Arima v\u00e0 c\u1ed9ng s\u1ef1 [33] th\u1ea5y r\u1eb1ng, khi \u0111\u1eb7t tr\u1ee5c ngang kh\u1edbp g\u1ed1i vu\u00f4ng g\u00f3c v\u1edbi APA, c\u00e1c bi\u1ebfn ch\u1ee9ng c\u1ee7a kh\u1edbp \u0111\u00f9i ch\u00e8 gi\u1ea3m c\u00f3 \u00fd ngh\u0129a so v\u1edbi khi \u0111\u1eb7t tr\u1ee5c n\u00e0y song song v\u1edbi tr\u1ee5c PCA. Kh\u00f4ng gi\u1ed1ng nh\u01b0 PCA, APA v\u1eabn c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong tr\u01b0\u1eddng h\u1ee3p ph\u1ea7n x\u01b0\u01a1ng ph\u00eda sau l\u1ed3i c\u1ea7u b\u1ecb m\u00f2n ho\u1eb7c thi\u1ec3u s\u1ea3n. M\u1ed9t s\u1ed1 t\u00e1c gi\u1ea3 \u0111\u00e3 ch\u1ee9ng minh r\u1eb1ng c\u00f3 m\u1ed9t kho\u1ea3ng sai s\u1ed1 kh\u00e1 r\u1ed9ng khi s\u1eed d\u1ee5ng tr\u1ee5c APA \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ed9 xoay cho LC\u0110. Poilvache v\u00e0 c\u1ed9ng s\u1ef1 [3] nghi\u00ean c\u1ee9u tr\u00ean 100 kh\u1edbp g\u1ed1i tho\u00e1i ho\u00e1, nh\u1eadn th\u1ea5y r\u1eb1ng s\u1ef1 thi\u1ec3u s\u1ea3n n\u1eb7ng c\u1ee7a r\u00f2ng r\u1ecdc g\u00e2y ra xoay ngo\u00e0i qu\u00e1 m\u1ee9c c\u1ee7a ph\u1ea7n LC\u0110. Nagamine v\u00e0 c\u1ed9ng s\u1ef1 [17] c\u0169ng l\u01b0u \u00fd r\u1eb1ng, \u0111\u01b0\u1eddng vu\u00f4ng g\u00f3c v\u1edbi APA \u1edf kh\u1edbp g\u1ed1i b\u00ecnh th\u01b0\u1eddng xoay ngo\u00e0i kho\u1ea3ng 3,5\u00b0 so v\u1edbi tr\u1ee5c PCA tr\u00ean phim ch\u1ee5p c\u1eaft l\u1edbp vi t\u00ednh \u1edf 84 kh\u1edbp g\u1ed1i, v\u00e0 xoay ngo\u00e0i h\u01a1n \u1edf nh\u1eefng tr\u01b0\u1eddng h\u1ee3p tho\u00e1i h\u00f3a di\u1ec7n kh\u1edbp \u0111\u00f9i – ch\u00e0y trong. Vi\u1ec7c s\u1eed d\u1ee5ng \u0111\u01a1n \u0111\u1ed9c tr\u1ee5c APA \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n tho\u00e1i h\u00f3a kh\u1edbp \u0111\u00f9i – ch\u00e0y trong l\u00e0m xoay ngo\u00e0i qu\u00e1 m\u1ee9c LC\u0110 v\u00e0 do \u0111\u00f3, s\u1ebd l\u00e0m m\u1ea5t v\u1eefng kh\u1edbp g\u1ed1i khi g\u1ea5p. Trong m\u1ed9t nghi\u00ean c\u1ee9u kh\u00e1c, Yau v\u00e0 c\u1ed9ng s\u1ef1 [30] nh\u1eadn th\u1ea5y s\u1ef1 sai l\u1ec7ch l\u00ean t\u1edbi 32\u00b0 (t\u1eeb 15\u00b0 xoay ngo\u00e0i \u0111\u1ebfn 17\u00b0 xoay trong) khi s\u1eed d\u1ee5ng tr\u1ee5c APA \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u1ed9 xoay c\u1ee7a ph\u1ea7n LC\u0110.<\/p>\n

2.3. Tr\u1ee5c sau l\u1ed3i c\u1ea7u \u0111\u00f9i (Posterior Condylar axis – PCA)<\/h3>\n

Tr\u1ee5c sau l\u1ed3i c\u1ea7u x\u01b0\u01a1ng \u0111\u00f9i l\u00e0 m\u1ed9t \u0111\u01b0\u1eddng k\u1ebb ti\u1ebfp tuy\u1ebfn v\u1edbi b\u1edd sau c\u1ee7a hai l\u1ed3i c\u1ea7u \u0111\u00f9i. G\u00f3c t\u1ea1o tr\u1ee5c PCA v\u1edbi tr\u1ee5c sTEA g\u1ecdi l\u00e0 g\u00f3c xoay c\u1ee7a l\u1ed3i c\u1ea7u x\u01b0\u01a1ng \u0111\u00f9i (rotated condylar angle) [17]. Khi gi\u1ea3i ph\u1eabu ph\u1ea7n sau l\u1ed3i c\u1ea7u \u0111\u00f9i b\u00ecnh th\u01b0\u1eddng, PCA s\u1ebd xoay trong 3\u00b0 – 5\u00b0 so v\u1edbi m\u1eb7t c\u1eaft x\u01b0\u01a1ng \u0111\u00f9i theo \u0111\u01b0\u1eddng vu\u00f4ng g\u00f3c v\u1edbi APA, \u0111i\u1ec1u n\u00e0y gi\u00fap \u0111\u1ecbnh h\u01b0\u1edbng cho m\u1eb7t c\u1eaft x\u01b0\u01a1ng ch\u00e0y. \u0110\u01b0\u1eddng c\u1eaft x\u01b0\u01a1ng ch\u00e0y vu\u00f4ng g\u00f3c v\u1edbi tr\u1ee5c c\u01a1 h\u1ecdc s\u1ebd lo\u1ea1i b\u1ecf s\u1ef1 v\u1eb9o trong 3\u00b0 c\u1ee7a m\u1eb7t kh\u1edbp x\u01b0\u01a1ng ch\u00e0y. Do \u0111\u00f3, vi\u1ec7c xoay ngo\u00e0i 3\u00b0 c\u1ee7a l\u1ed3i c\u1ea7u \u0111\u00f9i s\u1ebd gi\u00fap cho kho\u1ea3ng g\u1ea5p \u0111\u01b0\u1ee3c \u0111\u1ed1i x\u1ee9ng, t\u1ee9c l\u00e0 t\u1ea1o th\u00e0nh h\u00ecnh ch\u1eef nh\u1eadt. \u1ede c\u00e1c kh\u1edbp g\u1ed1i kh\u00f4ng c\u00f3 s\u1ef1 l\u1ec7ch tr\u1ee5c c\u01a1 h\u1ecdc, v\u1eb9o trong \u00edt v\u00e0 kh\u00f4ng b\u1ecb thi\u1ebfu s\u1ea3n l\u1ed3i c\u1ea7u \u0111\u00f9i, c\u00e1c d\u1ee5ng c\u1ee5 \u0111\u1ecbnh v\u1ecb d\u1ef1a v\u00e0o \u0111\u01b0\u1eddng PCA \u0111\u01b0\u1ee3c thi\u1ebft k\u1ebf \u0111\u1ec3 b\u1ea3o \u0111\u1ea3m l\u00e1t c\u1eaft b\u1edd tr\u01b0\u1edbc v\u00e0 b\u1edd sau l\u1ed3i c\u1ea7u \u0111\u00f9i xoay ngo\u00e0i 3\u00b0 – 5\u00b0 so v\u1edbi tr\u1ee5c PCA. Nh\u1eefng d\u1ee5ng c\u1ee5 n\u00e0y th\u01b0\u1eddng \u0111\u01a1n gi\u1ea3n v\u00e0 kh\u00e1 ch\u00ednh x\u00e1c (H\u00ecnh 11). Trong m\u1ed9t nghi\u00ean c\u1ee9u kh\u00e1c, Hungerford v\u00e0 Krackow[18] khuy\u00ean n\u00ean s\u1eed d\u1ee5ng tr\u1ee5c PCA \u0111\u1ec3 c\u1eaft xoay ngo\u00e0i l\u1ed3i c\u1ea7u \u0111\u00f9i, sau \u0111\u00f3 s\u1ebd ki\u1ec3m tra c\u00e1c l\u00e1t c\u1eaft xem c\u00f3 song song v\u1edbi tr\u1ee5c sTEA kh\u00f4ng.<\/p>\n

Tuy nhi\u00ean, vi\u1ec7c s\u1eed d\u1ee5ng tr\u1ee5c PCA c\u0169ng c\u00f3 nhi\u1ec1u b\u1ea5t l\u1ee3i do s\u1ef1 kh\u00e1c nhau v\u1ec1 \u0111\u1eb7c \u0111i\u1ec3m gi\u1ea3i ph\u1eabu c\u1ee7a m\u1ed7i b\u1ec7nh nh\u00e2n, kh\u00f3 \u0111i\u1ec1u ch\u1ec9nh ch\u00ednh x\u00e1c trong tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh nh\u00e2n b\u1ecb bi\u1ebfn d\u1ea1ng kh\u1edbp g\u1ed1i n\u1eb7ng ho\u1eb7c thay l\u1ea1i kh\u1edbp g\u1ed1i. \u1ede bi\u1ebfn d\u1ea1ng g\u1ed1i v\u1eb9o ngo\u00e0i, b\u1edd sau c\u1ee7a l\u1ed3i c\u1ea7u ngo\u00e0i th\u01b0\u1eddng b\u1ecb m\u00f2n ho\u1eb7c thi\u1ec3u s\u1ea3n, c\u00f2n \u1edf bi\u1ebfn d\u1ea1ng g\u1ed1i v\u1eb9o trong, b\u1edd sau c\u1ee7a l\u1ed3i c\u1ea7u trong th\u01b0\u1eddng b\u1ecb m\u00f2n nhi\u1ec1u h\u01a1n. Do \u0111\u00f3, s\u1eed d\u1ee5ng tr\u1ee5c PCA \u1edf nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y s\u1ebd d\u1eabn \u0111\u1ebfn nh\u1eefng sai l\u1ec7ch l\u1edbn c\u1ee7a tr\u1ee5c ngang g\u1ed1i[1], [2], [3],[5],[19],[20].<\/p>\n

\"hinh-5.2-dung-cu-dinh-vi-dua-vao-truc-pca-trong-phau-thuat-thay-khop-goi\"
H\u00ecnh 5.2. D\u1ee5ng c\u1ee5 \u0111\u1ecbnh v\u1ecb d\u1ef1a v\u00e0o tr\u1ee5c PCA [16]<\/figcaption><\/figure>T\u00f3m l\u1ea1i, nh\u1eefng sai l\u1ec7ch khi s\u1eed d\u1ee5ng k\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp d\u1ef1a v\u00e0o c\u00e1c tr\u1ee5c gi\u1ea3i ph\u1eabu c\u00f3 th\u1ec3 x\u1ea3y ra khi c\u00f3 s\u1ef1 thay \u0111\u1ed5i v\u1ec1 gi\u1ea3i ph\u1eabu c\u1ee7a c\u00e1c m\u1ed1c x\u01b0\u01a1ng n\u00e0y. V\u00ec v\u1eady, vi\u1ec7c s\u1eed d\u1ee5ng t\u1ea5t c\u1ea3 c\u00e1c tr\u1ee5c gi\u1ea3i ph\u1eabu x\u01b0\u01a1ng \u0111\u00f9i, so s\u00e1nh v\u00e0 \u0111\u1ed1i chi\u1ebfu c\u00e1c tr\u1ee5c n\u00e0y v\u1edbi nhau \u0111\u1ec3 quy\u1ebft \u0111\u1ecbnh g\u00f3c xoay ngo\u00e0i c\u1ee7a ph\u1ea7n \u0111\u00f9i l\u00e0 r\u1ea5t quan tr\u1ecdng v\u00e0 c\u1ea7n thi\u1ebft.<\/p>\n

K\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp c\u00f3 \u01b0u \u0111i\u1ec3m<\/strong>:<\/p>\n

    \n
  • B\u1ea3o t\u1ed3n \u0111\u01b0\u1ee3c v\u1ecb tr\u00ed c\u1ee7a khe kh\u1edbpg\u1ed1i so v\u1edbi tr\u01b0\u1edbc m\u1ed5 trong \u0111a s\u1ed1 c\u00e1c tr\u01b0\u1eddng h\u1ee3p.<\/li>\n
  • H\u1ea1n ch\u1ebf t\u1ed1i thi\u1ec3u s\u1ef1 m\u1ea5t v\u1eefng \u1edf kho\u1ea3ng n\u1eeda g\u1ea5p.<\/li>\n
  • Tr\u1ef1c quan v\u00e0 d\u1ec5 th\u1ef1c hi\u1ec7n h\u01a1n so v\u1edbi k\u1ef9 thu\u1eadt c\u00e2n b\u1eb1ng kho\u1ea3ng<\/li>\n<\/ul>\n

    Tuy nhi\u00ean c\u0169ng c\u00f3 m\u1ed9t s\u1ed1 nh\u01b0\u1ee3c \u0111i\u1ec3m<\/strong> sau:<\/p>\n

      \n
    • Kh\u00f3 x\u00e1c \u0111\u1ecbnh ch\u00ednh x\u00e1c c\u00e1c m\u1ed1c x\u01b0\u01a1ng trong khi ph\u1eabu thu\u1eadt, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edfc\u00e1c kh\u1edbp bi\u1ebfn d\u1ea1ng nhi\u1ec1u th\u00ec vi\u1ec7c c\u1eaft x\u01b0\u01a1ng v\u00e0 thi\u1ebft l\u1eadp g\u00f3c xoay ngo\u00e0i c\u1ee7a ph\u1ea7n \u0111\u00f9i c\u00f3 th\u1ec3 s\u1ebd kh\u00f4ng ch\u00ednh x\u00e1c theo y\u00eau c\u1ea7u.<\/li>\n
    • Tr\u1ee5c xuy\u00ean m\u1ecfm tr\u00ean l\u1ed3i c\u1ea7u x\u01b0\u01a1ng \u0111\u00f9i sTEA th\u00ec kh\u00f4ng d\u1ec5 x\u00e1c \u0111\u1ecbnh v\u00e0 c\u00f3 sai s\u1ed1 kh\u00e1 l\u1edbn.<\/li>\n
    • Gi\u1ea3i ph\u00f3ng m\u00f4 m\u1ec1m th\u01b0\u1eddng c\u00f3 khuynh h\u01b0\u1edbng l\u00e0m t\u0103ng \u201ckho\u1ea3ng g\u1ea5p\u201d so v\u1edbi \u201ckho\u1ea3ng du\u1ed7i\u201d. Khi \u1ea5y bu\u1ed9c ph\u1ea3i c\u1eaft th\u00eam \u0111\u1ea7u xa x\u01b0\u01a1ng\u0111\u00f9i \u0111\u1ec3 cho 2 kho\u1ea3ng c\u00e1ch n\u00e0y b\u1eb1ng nhau, v\u00e0 nh\u01b0 th\u1ebf l\u00e0 l\u00e0m t\u0103ng chi\u1ec1u cao c\u1ee7a kh\u1edbp nh\u00e2n t\u1ea1o (thay \u0111\u1ed5i \u201cJoint line\u201d). Khi t\u0103ng chi\u1ec1u cao c\u1ee7a kh\u1edbp nh\u00e2n t\u1ea1o s\u1ebd \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn \u0111\u1ed9ng h\u1ecdc c\u1ee7a kh\u1edbp g\u1ed1i, \u0111\u1eb7c bi\u1ec7t l\u00e0 s\u1ef1 tr\u01b0\u1ee3t c\u1ee7a x\u01b0\u01a1ng b\u00e1nh ch\u00e8 tr\u00ean r\u00e3nh l\u1ed3i c\u1ea7u \u0111\u00f9i nh\u00e2n t\u1ea1o[19].<\/li>\n<\/ul>\n

      T\u00c0I LI\u1ec6U THAM KH\u1ea2O<\/h3>\n
        \n
      1. Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS. Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res. 1993;(286):40-7.<\/li>\n
      2. Griffin FM, Math K, Scuderi GR, Insall JN, Poilvache PL. Anatomy of the epicondyles of the distal femur: MRI analysis of normal knees. J Arthroplasty. 2000; 15(3): 354-9.<\/li>\n<\/ol>\n
          \n
        1. Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE. Rotational landmarks and sizing of the distal femur in total knee arthroplasty, Clin Orthop Relat Res. 1996;(331):35-46.<\/li>\n
        2. Whiteside LA, Arima J. The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Rclat Res. 1995;(321): 168-72.<\/li>\n
        3. Mantas JP, Bloebaum RD, Skedros JG, Hofmann AA. Impli- cations of reference axes used for rotational alignment of the femoral component in primary and revision knee arthro- plasty. J 1992;7(4):531-<\/li>\n
        4. Schni\u01b0r C, Nessler J, Konig DP. Is referencing the posterior condyles sufficient to achieve a rectangular flexion gap in total\u00a0\u00a0 knee arthroplasty? Int Orthop. 2009;33(6): 1561-5.<\/li>\n<\/ol>\n
            \n
          1. Aglietti P, Sensi L, Cuomo P, Ciardullo A. Rotational position of femoral and tibial components in TKA using the femoral transepicondylar axis. Clin Orthop Relat Res. 2008;466(11):2751-5.<\/li>\n
          2. Diduch DR, Insall JN, Scott WN, Scuderi GR, Font-Rodri- guez D. Total knee replacement in young, active patients: long-term follow-up and functional outcome. J Bone Joint SurgAm. 1997;79(4):575-82.<\/li>\n
          3. Miller MC, Berger RA, Petrella AJ, Karmas A, Rubash HE. Optimizing femoral component rotation in total knee ar- throplasty. Clin Orthop Relat Res. 2001;(392):38-45.<\/li>\n
          4. Olcott CW, Scott A comparison of 4 intraoperative methods to determine femoral component rotation during total knee arthroplasty. J Arthroplasty. 2000;15(l):22-6.<\/li>\n
          5. Insall JN, Scuderi GR, Komistek RD, Math K, Dennis DA, Anderson DT, Correlation between condylar lift-off and emoral component alignment. Clin Orthop Relat Res. 2002;(403): 143-52.<\/li>\n
          6. Hatayama K, Terauchi M, Higuchi H, Yanagisawa S, Sailo K, Takagishi K. Relationship between femoral component rota- tion and total knee flexion gap balance on modified axial .1 Arthroplasty. 2011;26(4):649-53.<\/li>\n
          7. Jerosch J, Peuker E, Philipps B, Filler Interindividual re- producibility in perioperative rotational alignment of femo- ral components in knee prosthetic surgery using the tran- sepicondylar axis. Knee Surg Sports Traumatol Arthrosc. 2002; 10(3): 194-7.<\/li>\n
          8. Kinzel V, Ledger M, Shakespeare D. Can the epicondylar axis be defined accurately in total knee arthroplasty? Knee. 2005;12(4):293-6.<\/li>\n
          9. Yau WP, Chiu KY, Tang WM. How precise is the determi- nation of rotational alignment of the femoral prosthesis in total knee arthroplasty: an in vivo study. J Arthroplasty. 2007;22(7): 1042-8.<\/li>\n
          10. Katz MA, Beck TD, Silber JS, Seldes RM, Lotke PA. Deter- mining femoral rotational alignment in total knee arthro- plasty: reliability of techniques. J 2001; 16(3): 301-5.<\/li>\n
          11. Nagamine R, Miura H, Inouc Y, et Reliability of the an- teroposterior axis and the posterior condylar axis for deter- mining rotational alignment of the femoral component in total knee arthroplasty. J Orthop Sci. 1998;3(4): 194-8.<\/li>\n
          12. Hungerford DS, Krackow KA. Total joint arthroplasty of the knee. Clin Orthop Relat Res. 1985;(l92):23-33.<\/li>\n
          13. Pagnano MW, I [anssen AD. Varus tibial joint line obliquity: a potential cause of femoral component malrotation. Clin Orthop Relat Res. 2001;(392):68-74.<\/li>\n
          14. Griffin FM, Insall JN, Scuderi GR. The posterior condylar angle in osteoarthritic J Arthroplasty. 1998; 13(7):812-5.<\/li>\n<\/ol>\n

             <\/p>\n

             <\/p>\n","protected":false},"excerpt":{"rendered":"

            Ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i to\u00e0n ph\u1ea7n\u00a0 l\u00e0 ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb tri\u1ec7t \u0111\u1ec3 v\u00e0 hi\u1ec7u qu\u1ea3 b\u1ec7nh l\u00fd tho\u00e1i ho\u00e1 kh\u1edbp g\u1ed1i m\u1ee9c \u0111\u1ed9 n\u1eb7ng. K\u1ef9 thu\u1eadt c\u1eaft x\u01b0\u01a1ng \u0111\u1ed9c l\u1eadp l\u00e0 1 trong 2 k\u1ef9 thu\u1eadt c\u01a1 b\u1ea3n c\u1ee7a ph\u1eabu thu\u1eadt thay kh\u1edbp g\u1ed1i to\u00e0n ph\u1ea7n. 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