金属对金属大头径微创全髋关节置换术治疗青中年股骨头坏死的临床研究

目的探讨金属对金属（金对金）大头径假体微创全髋关节置换术（THA）治疗青中年股骨头坏死Ⅲ、Ⅳ期的临床疗效。方法本组32例（35髋）青中年股骨头缺血性坏死Ⅲ、Ⅳ期患者，年龄24～59岁，平均45岁，术前髋关节Harris评分平均（37．9±7．5）分；以改良后外侧小切口、肌间隙人路、充分保留关节动力性组织结构为特征的金对金大头径微创THA治疗。术中严格采取正确的假体植入技术，术中保留完整的软骨下骨和髋臼横韧带，击入臼杯时一次性安装成功，正确运用万古霉素预防感染。术后口服利伐沙班片抗凝，术后12h开放负压引流及卧床行功能锻炼，术后第2天拔除引流管后扶拐下地部分负重行走，术后2—3周患者即可弃拐完全负重行走。结果本组32例35髋患者均获随访，随访时间为12个月～6年，平均为4年。所有患者切口均一期愈合，无深静脉血栓形成、关节脱位、坐骨神经损伤、髋臼及股骨疲劳骨折、关节疼痛等严重并发症，X线片示髋关节假体位置均良好，无松动、移位、股骨柄下沉、假体周围骨折等表现。末次随访Harris评分由术前平均（37．9±7．5）分，提高至术后平均（92．2±4．6）分，前后比较有统计学意义（t=44．341，P〈0．05）。所有患者末次随访时髋关节功能明显优于术前，均对治疗效果满意，完全恢复正常生活及工作。结论采用金对金大头径微创THA治疗青中年股骨头坏死Ⅲ、Ⅳ期患者，能够明显降低手术风险，缩短卧床时问，迅速恢复髋关节功能，减少手术并发症，取得了满意的近期临床疗效。随着基础和临床研究的不断深入，金对金大头径髋关节假体的长期疗效还需要进一步探讨。

Clinical application of minimally invasive large-size metal-on-metal total hip replacement for necrosis of femoral head in young and middle-aged patients

Objective To discuss clinical application of big size metal-on-metal total hip replacement with minimally invasive method for stage Ⅲ/Ⅳ avascular necrosis of the femoral head in the young and the middle-aged patients. Methods 32 patients （35 hips ） whose femoral heads were stage Ⅲ/Ⅳ avascular necrosis were chosen, with age ranging from 24 to 59 years, 45 years in average. The average Harris score was 37. 9. Minimally invasive improved posterolateral incision and the muscle space approach used; the dynamic structure was fully retained; the large size metal-on-metal total hip replacement was performed in all the cases. The correct prosthesis implantation technique was adopted during the operation ; the subchondral bone and the transverse ligament of acetabulum were kept intact ; and the cup was set smoothly. The vancomycin was used to prevent infection, and rivaroxaban was taken for anticoagulation. The vaccum suction drainage was adopted for 12 hours after the operation. On the second day, the patients were required to walk with partial weight-bearing. Full weight-bearing walk was done in two or three weeks after surgery. Results 32 cases with 35 hips were followed up for 4 years in average （range, from 12 months to 6 years）. All incisions were primary healing. There was no deep venous thrombosis, dislocation, sciatic nerve injury, acetabular and femoral fatigue fracture, joint pain or other serious complications. X-ray showed that the location of hip prosthesis was good, without loosening, subsidence, displacement, or periprosthetic fractures. At the last follow-up, Harris score was increased from a preoperative mean of （37.9 ± 7.5 ） to a postoperative mean of （92. 2 ± 4. 6）, which was statistically significant （t =44. 341, P 〈0.05）. All the hip functions were better than the preoperative ones; all the patients achieved satisfactory curative effects, and completely restored normal life and work. Conclusions Minimally invasive total hip replacement with large size metal-on-metal prothesis for stage Ⅲ/Ⅳ avascular necrosis of the femoral head in young and middle-aged patients, could significantly reduce the operation risks and complications, shorten the time of lying in bed, restore the hip joint function rapidly, and achieve satisfactory clinical effects. The long-term effects of large size metal on metal hip prosthesis still needs further discussion.