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Surgical Technique: Free Vascularized Fibular Graft for AVN

  • Richard C. MatherIII
  • Andrew E. Federer
  • David S. Ruch
Living reference work entry

Abstract

Avascular necrosis (AVN) or osteonecrosis of the femoral head (ONFH) is a common cause of hip pain and disability in a young patient demographic with an average age of mid-30s. If left untreated, approximately 80 % of cases of ONFH will result in femoral head collapse and hip degeneration necessitating total hip arthroplasty (THA) in a mean of 2 years. The relatively poor outcomes and requisite lifestyle changes associated with THA in this patient population have challenged surgeons to seek alternative treatment options. Vascularized bone grafts have been shown to have better radiographical and clinical results compared to nonvascularized bone grafts. Of these options, free vascularized fibular graft (FVFG) is the treatment of choice for its structural and vascular support within the femoral head. Improved technique has led to complication rates, including donor-site morbidity, statistically similar to that of nonvascular fibular grafts. When used in young patients with precollapse ONFH, FVFG can greatly improve patient outcome, with lower rates of conversion to THA than other treatment modalities.

References

  1. 1.
    Jacobs B. Epidemiology of traumatic and nontraumatic osteonecrosis. Clin Orthop Relat Res. 1978;130:51–67.PubMedGoogle Scholar
  2. 2.
    Coventry MB, Beckenbaugh RD, Nolan DR, Ilstrup DM. 2,012 total hip arthroplasties. A study of postoperative course and early complications. J Bone Joint Surg Am. 1974;56(2):273–84.PubMedGoogle Scholar
  3. 3.
    Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77(3):459–74.PubMedGoogle Scholar
  4. 4.
    Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). N Engl J Med. 1992;326(22):1473–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Forgon M, Montsko P. Muscle-pedicle grafts or muscle-pedicle-bone grafts in the treatment of avascular necrotic femoral heads. Arch Orthop Trauma Surg. 1996;115(3–4):223–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Tetik C, Basar H, Bezer M, Erol B, Agir I, Esemenli T. Comparison of early results of vascularized and non-vascularized fibular grafting in the treatment of osteonecrosis of the femoral head. Acta Orthop Traumatol Turc. 2011;45(5):326–34.PubMedGoogle Scholar
  7. 7.
    Etienne G, Mont MA, Ragland PS. The diagnosis and treatment of nontraumatic osteonecrosis of the femoral head. Instr Course Lect. 2004;53:67–85.PubMedGoogle Scholar
  8. 8.
    Steinberg M. Diagnostic imaging and role of stage and lesion size in determining outcome in osteonecrosis of the femoral head. Tech Orthop. 2001;16:6–15.CrossRefGoogle Scholar
  9. 9.
    Lang P, Jergesen HE, Moseley ME, Block JE, Chafetz NI, Genant HK. Avascular necrosis of the femoral head: high-field-strength MR imaging with histologic correlation. Radiology. 1988;169(2):517–24.PubMedCrossRefGoogle Scholar
  10. 10.
    Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;324:169–78.PubMedCrossRefGoogle Scholar
  11. 11.
    Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage. Indian J Orthop. 2009;43(1):6–16.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Hungerford D Bone marrow pressure, venography, and core decompression in ischemic necrosis of the femoral head. The Hip: Proceedings of the seventh open scientific meeting of the hip society. 1979;218.Google Scholar
  13. 13.
    Ficat R, Arlet J. Functional investigation of bone under normal conditions. In: Ficat R, Arlet J, Hungerford D, editors. Ischemia and necrosis of bone. Baltimore: Williams & Wilkins; 1980. p. 29–52.Google Scholar
  14. 14.
    Mont MA, Einhorn TA, Sponseller PD, Hungerford DS. The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. J Bone Joint Surg (Br). 1998;80(1):56–62.CrossRefGoogle Scholar
  15. 15.
    Ganz R, Buchler U. Overview of attempts to revitalize the dead head in aseptic necrosis of the femoral head – osteotomy and revascularization. Hip. 1983;296–305.Google Scholar
  16. 16.
    Buckley PD, Gearen PF, Petty RW. Structural bone-grafting for early atraumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1991;73(9):1357–64.PubMedGoogle Scholar
  17. 17.
    Chacha PB. Vascularised pedicular bone grafts. Int Orthop. 1984;8(2):117–38.PubMedCrossRefGoogle Scholar
  18. 18.
    Meyers MH. The treatment of osteonecrosis of the hip with fresh osteochondral allografts and with the muscle pedicle graft technique. Clin Orthop Relat Res. 1978;130:202–9.PubMedGoogle Scholar
  19. 19.
    Lee CK, Rehmatullah N. Muscle-pedicle bone graft and cancellous bone graft for the “silent hip” of idiopathic ischemic necrosis of the femoral head in adults. Clin Orthop Relat Res. 1981;158:185–94.PubMedGoogle Scholar
  20. 20.
    Baksi DP. Treatment of osteonecrosis of the femoral head by drilling and muscle-pedicle bone grafting. J Bone Joint Surg (Br). 1991;73(2):241–5.Google Scholar
  21. 21.
    Iwata H, Torii S, Hasegawa Y, et al. Indications and results of vascularized pedicle iliac bone graft in avascular necrosis of the femoral head. Clin Orthop Relat Res. 1993;295:281–8.PubMedGoogle Scholar
  22. 22.
    Stein H, Volpin G, Horer D. Vascularized muscle pedicle flap for osteonecrosis of the femoral head. Orthopedics. 2002;25(5):485–8.PubMedGoogle Scholar
  23. 23.
    Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995;77(5):681–94.PubMedGoogle Scholar
  24. 24.
    Brunelli G, Brunelli G. Free microvascular fibular transfer for idiopathic femoral head necrosis: long-term follow-up. J Reconstr Microsurg. 1991;7(4):285–95.PubMedCrossRefGoogle Scholar
  25. 25.
    Judet H, Judet J, Gilbert A. Vascular microsurgery in orthopaedics. Int Orthop. 1981;5(2):61–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Kim SY, Kim YG, Kim PT, Ihn JC, Cho BC, Koo KH. Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head. J Bone Joint Surg Am. 2005;87(9):2012–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Plakseychuk AY, Kim SY, Park BC, Varitimidis SE, Rubash HE, Sotereanos DG. Vascularized compared with nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003;85-A(4):589–96.PubMedGoogle Scholar
  28. 28.
    Tang CL, Mahoney JL, McKee MD, Richards RR, Waddell JP, Louie B. Donor site morbidity following vascularized fibular grafting. Microsurgery. 1998;18(6):383–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Fang T, Zhang EW, Sailes FC, McGuire RA, Lineaweaver WC, Zhang F. Vascularized fibular grafts in patients with avascular necrosis of femoral head: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2013;133(1):1–10.PubMedCrossRefGoogle Scholar
  30. 30.
    Yoshimura M, Shimamura K, Iwai Y, Yamauchi S, Ueno T. Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula. J Bone Joint Surg Am. 1983;65(9):1295–301.PubMedGoogle Scholar
  31. 31.
    Hungerford DS, Zizic TM. Alcoholism associated ischemic necrosis of the femoral head. Early diagnosis and treatment. Clin Orthop Relat Res. 1978;130:144–53.PubMedGoogle Scholar
  32. 32.
    Urbaniak JR, Harvey EJ. Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg. 1998;6(1):44–54.PubMedGoogle Scholar
  33. 33.
    Marchant Jr MH, Zura RD, Urbaniak JR, Aldridge 3rd JM. Hip incision planning for free vascularized fibular grafting of the proximal femur: a handy tip. J Surg Orthop Adv. 2007;16(4):204–6.PubMedGoogle Scholar
  34. 34.
    Aldridge 3rd JM, Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique. J Bone Joint Surg Am. 2004;86-A Suppl 1:87–101.PubMedGoogle Scholar
  35. 35.
    Eward WC, Rineer CA, Urbaniak JR, Richard MJ, Ruch DS. The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible? Clin Orthop Relat Res. 2012;470(10):2819–26.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Richard C. MatherIII
    • 1
  • Andrew E. Federer
    • 2
  • David S. Ruch
    • 3
  1. 1.Orthopaedic Surgery, Duke University School of MedicineDurhamUSA
  2. 2.Rush Medical SchoolChicagoUSA
  3. 3.Duke University Health SystemDurhamUSA

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