Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: Results of 7.6-year follow-up

Abstract

Objectives: The aim of this study was to determine long term follow up of the patients who had femoral head osteonecrosis and had been treated with free vascularized fibular grafting.

Patients and methods: We retrospectively reviewed 28 hips of 21 patients who had undergone free vascularized fibular grafting for the treatment of osteonecrosis of femoral head. There were 16 male and 5 female patients. The mean age of the patients at the time of surgery was 30.7 years (between 15 and 53 years). The mean follow-up time was 7.6 years (between 5 years and 9.2 years).

Results: During follow-up, one patient died because of leukemia, and one patient was lost. The remaining 26 hips of 19 patients were evaluated. According to the Ficat classification, at the time of surgery, 17 hips were in grade 2 and 9 hips were in grade 3. The post-operative Harris hip scores in grade II disease were excellent in 12 patients, good in 3 patients, and fair in 1 patient. In grade III disease, 1 patient was excellent, 5 patients were good, and 1 patient was fair. There was a significant increase in HHS scores (61 ± 9.7 vs 84 ± 17.8, p < 0.001).

Conclusion: Free vascularized fibular grafting yields extremely good results, particularly in pre-collapse stages of disease in young patients. The operation time does not mark increased if the surgical team is "familiar" with the procedure, and the residual fibular defect of the donor site does not impair the functions of daily living.

Level of evidence: Level IV, Therapeutic study.

Keywords: Free vascularized fibular grafting; Osteonecrosis of the femoral head.

Fig. 1

Completely scrubbed lower extremity, sterile tourniquet used.

Fig. 2

Debridement of osteonecrosis field and evaluation of cavity formed by contrast agent.

Fig. 3

View of lateral femoral circumflex artery in the fatty tissue on vastus intermedius.

Fig. 4

Sixth postoperative year roentgenogram of patient whose hips were operated at stage 2.

Fig. 5

Seventh and eighth postoperative year roentgenograms of patient whose hips were operated at stage 3.

Fig. 6

Straight reamers in increasing size provide a tunnel size matching with the fibula (a). Ball-tipped reamers (b) and reverse cutters (c) are used inside the lesion. Graft impactor composed of a drill with large helix angle inside the metal tube with distal openings. Grafts are placed in the tube and the drill is advanced through. Clockwise spinning of drill impacts grafts inside the cavity (d). Removal of the tube leaves a space to inset fibular graft.

Fig. 7

Periosteum stripped and folded at the end of the fibula and view of cambium layer.