Treatment of osteonecrosis in the hip of pediatric patients by free vascularized fibular graft

The purpose of the current study was to review the demographics and etiologies of symptomatic femoral head osteonecrosis in the pediatric and adolescent population and to assess the results of treatment using free vascularized fibular grafting. A group of patients with femoral head osteonecrosis who were treated with free vascularized fibular grafting was reviewed. Patients who were studied were 18 years of age or younger at the time of surgery. Records were examined for demographic data, etiology of osteonecrosis, stage of the disease at time of surgery, and results of treatment including preoperative and postoperative Harris hip scores. Eighty-two pediatric and adolescent patients with osteonecrosis of the femoral head underwent 90 free vascularized fibular grafting procedures. Fifty patients (54 hips) who have been followed up at least 2 or more years (average, 4.3 years) constituted the study group. At the last followup, total hip arthroplasty was performed in seven hips (seven patients) and hip fusion was performed in one hip (one patient). The average Harris hip scores in patients who did not undergo total hip arthroplasty improved from a preoperative average of 55.3 points to 90.2 points at the latest followup. Treatment of patients with osteonecrosis with free vascularized fibular grafting resulted in a lower rate of conversion to total hip arthroplasty or fusion (16%) in pediatric and adolescent patients when compared with conversion to total hip arthroplasty in adults (25%). The quality of life as evidenced by the increased Harris hip scores was improved significantly in this group of pediatric and adolescent patients.     

Vascularized compared with nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head

BACKGROUND: We are not aware of any clinical studies in the literature comparing the results of vascularized and nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purpose of this study was to compare the clinical results of free vascularized fibular grafting with those of nonvascularized fibular grafting. METHODS: Two hundred patients (220 hips) with osteonecrosis of the femoral head were treated with free vascularized fibular grafting at the University of Pittsburgh Medical Center, and ninety-nine patients (123 hips) were treated with nonvascularized fibular grafting at the Kyungpook National University Hospital in Korea. From these populations, two groups of fifty hips each, followed for a minimum of three years (average, five years), were matched by the stage, size, and etiology of the lesion and by the mean preoperative Harris hip score. A retrospective case-control study of these groups was then performed to compare the postoperative Harris hip scores as well as the prevalences of radiographic progression and collapse of the femoral head following free vascularized fibular grafting with those measures following nonvascularized fibular grafting. RESULTS: The mean Harris hip score improved for 70% of the hips treated with free vascularized fibular grafting: seventeen hips (34%) were rated excellent, fourteen (28%) were rated good, nine (18%) were rated fair, and ten (20%) were rated poor. The mean Harris hip score improved for 36% of the hips treated with nonvascularized fibular grafting: five hips (10%) were rated excellent; nine (18%), good; sixteen (32%), fair; and twenty (40%), poor. The rate of survival at seven years for the Stage-I and II hips (precollapse) was 86% after treatment with free vascularized fibular grafting compared with 30% after nonvascularized fibular grafting. CONCLUSIONS: The results of this study strongly suggest that vascularized fibular grafting is associated with better clinical and radiographic results.     

Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head

BACKGROUND: Osteonecrosis of the femoral head, a disease primarily affecting young adults, is often associated with collapse of the articular surface and subsequent arthrosis. Free vascularized fibular grafting has been reported to be successful for patients with early stages of osteonecrosis, but little is known about its efficacy after the femoral head has collapsed. METHODS: We retrospectively reviewed the results in a consecutive series of 188 patients (224 hips) who had undergone free vascularized fibular grafting, between 1989 and 1999, for the treatment of osteonecrosis of the hip that had led to collapse of the femoral head but not to arthrosis. The average duration of follow-up was 4.3 years (range, two to twelve years). We defined conversion to total hip arthroplasty as the failure end point, and we analyzed the contribution, to failure, of the size of the lesion, amount of preoperative collapse of the femoral head, etiology of the osteonecrosis, age of the patient, and bilaterality of the lesion. We used the Harris hip score to evaluate clinical status preoperatively and at the time of the most recent follow-up. RESULTS: The overall rate of survival was 67.4% for the hips followed for a minimum of two years and 64.5% for those followed for a minimum of five years. The mean preoperative Harris hip score was 54.5 points, and it increased to 81 points for the patients in whom the surgery succeeded; 63% of the patients in that group had a good or excellent result. There was a significant relationship between the outcome of the grafting procedure and the etiology of the osteonecrosis (p = 0.017). Patients in whom the osteonecrosis was idiopathic, associated with alcohol abuse, or posttraumatic fared worse than did those with other causes, including steroid use. Survival of the joint was not significantly related to the size of the femoral head lesion, but there was an increased relative risk of conversion to total hip arthroplasty with increasing lesion size and amount of collapse. Neither patient age nor bilaterality significantly affected outcome. CONCLUSIONS: Patients with postcollapse, predegenerative osteonecrosis of the femoral head appear to benefit from free vascularized fibular grafting, with good overall survival of the joint and significant improvement in the Harris hip score. The results of this femoral head-preserving procedure in patients with postcollapse osteonecrosis are superior to those of core decompression and nonoperative treatment, as reported in the literature. Patients with larger lesions and certain diagnoses, such as idiopathic and alcohol-related osteonecrosis, have worse outcomes.     

Treatment of osteonecrosis of the femoral head by free vascularized fibular grafting: an analysis of surgical outcome and patient health status.

OBJECTIVE: To evaluate the limb-specific outcome and general health status of patients with osteonecrosis of the femoral head treated with vascularized fibular grafting. DESIGN: A retrospective review. SETTING: A single tertiary care centre. PATIENTS: Fifty-five consecutive patients with osteonecrosis of the femoral head who underwent fibular grafting (8 bilaterally). INTERVENTION: Vascularized fibular grafting. OUTCOME MEASURES: Limb-specific scores (Harris Hip Score, St. Michael's Hospital Hip Score), general health status (Nottingham Health Profile, SF-36 health status survey) and radiographic outcome measures (Steinberg stage). RESULTS: Patients were young (mean age 34 years, range from 18 to 52 years) and 80% had advanced osteonecrosis (Steinberg stages IV and V). Fifty-nine hips were followed up for an average of 50 months (range from 24 to 117 months) after vascularized fibular grafting. Sixteen hips (27%) were converted to total hip arthroplasty (THA). To date, 73% of hips treated with vascularized fibular grafting have required no further surgery. Preoperative and postoperative Harris Hip Scores were 57.3 and 83.6 respectively (p < 0.001). As measured by patient-oriented health status questionnaires (SF-36, Nottingham Health Profile) and compared with population controls, patients had normal mental health scores and only slight decreases in physical component scores. CONCLUSIONS: Free vascularized fibular grafting for osteonecrosis of the femoral head provides satisfactory pain relief, functional improvement and general health status and halts the progression of symptomatic disease.     

Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head

BACKGROUND: Many authors have reported good results with the use of vascularized fibular grafts to treat large osteonecrotic lesions of the femoral head. To our knowledge, there have been no prospective case-controlled studies comparing the effectiveness of vascularized fibular grafting with that of nonvascularized fibular grafting for the prevention of progression and collapse of the lesion. METHODS: Nineteen patients (twenty-three hips) with a large osteonecrotic lesion of the femoral head (Stage IIC in ten hips, Stage IIIC in two, and Stage IVC in eleven, according to the classification system of Steinberg et al.) underwent vascularized fibular grafting. This group was retrospectively matched according to the etiology, stage, and size of the lesion to a group of nineteen patients (twenty-three hips) who underwent nonvascularized fibular grafting during the same time period. A prospective case-controlled study of the two groups, with a mean duration of follow-up of four years, was then performed. RESULTS: The mean Harris hip score improved for 70% of the hips treated with a vascularized graft and 35% of the hips treated with a nonvascularized graft (p < 0.05). At the time of the final follow-up, nine of the ten hips with a Stage-IIC lesion treated with a vascularized fibular graft had not collapsed whereas seven of the thirteen hips with a larger lesion (Stage IIIC or IVC) had collapsed. Three hips (13%) were converted to a total hip replacement. The mean dome depression measured 2.8 mm. In the group treated with a nonvascularized graft, five of the ten Stage-IIC hips had not collapsed and eleven of the thirteen hips with a larger lesion had collapsed. Five (22%) of the hips were converted to a total hip replacement. The mean dome depression measured 4.3 mm. The rates of radiographic progression and collapse were significantly lower and the mean dome depression was significantly less in the group treated with a vascularized fibular graft (p < 0.05). CONCLUSIONS: Vascularized fibular grafting was associated with better clinical results and was more effective than nonvascularized fibular grafting for the prevention of collapse of the femoral head in a matched population with a Steinberg Stage-IIC or larger osteonecrotic lesion. The results of vascularized grafting were best when the procedure was used to treat precollapse lesions (Steinberg Stage IIC).     

Free vascularized fibular grafting following failed core decompression for femoral head osteonecrosis

The results of treatment of femoral head osteonecrosis with free vascularized fibular grafting (FVFG) following failed core decompression (core decompression-FVFG [CD-FVFG] group: 32 hips) were reviewed and compared with those of a control group that underwent FVFG only (54 hips). Outcome was considered unsuccessful if total hip arthroplasty was subsequently performed. Total hip arthroplasty was performed in 15 and 20 hips of the CD-FVFG and control groups, respectively. When considering age, sex, and presence of bilateral disease, patients with previous core decompression did not have a significantly different failure rate from patients with FVFG only. However, patients with preoperative stage V osteonecrosis or corticosteroid use had worse outcomes after vascularized fibular grafting if they had a previous core decompression of the femoral head.     

Treatment of osteonecrosis of the femoral head in lymphoma patients by free vascularised fibular grafting

The purpose of this study was to assess the outcomes of treatment of femoral head osteonecrosis using free vascularised fibular grafting in patients with Hodgkin’s disease and non-Hodgkin’s lymphoma. We retrospectively reviewed seven patients (14 hips) with lymphoma who underwent free vascularised fibular grafting for osteonecrosis of the femoral head, evaluating pre- and postoperative Harris hip scores, visual analog scale (VAS) pain scores, hip range of motion and radiographs. Patients were followed up for a minimum of 1.5 years (mean, 3.3 years). All these patients exhibited good recovery without severe life-threatening complications. The mean Harris hip score improved from 69 to 88, while average VAS pain score decreased from 54 to 18. At the latest follow-up, we found improvement or unchanged radiographs in all three hips with initial Steinberg stage II osteonecrosis and in nine of 11 hips with stage III or IV osteonecrosis. No hips failed treatment and underwent total hip arthroplasty. The clinical data demonstrated that free vascularised fibular grafting can slow or even halt progression of necrosis, and improve the function of the hip and quality of life in lymphoma patients.     

Physicians and health professionals with osteonecrosis of the femoral head: results of management with free vascularized fibular grafting

Outcomes of free vascularized fibular grafting for the treatment of femoral head (FH) osteonecrosis between 1) physicians/health professionals and 2) a comparison group of the population at large was performed. Twenty-one healthcare providers (32 hips) were treated: 10 stage II, 7 stage III, and 15 stage IV were treated over a 13-year period. The control group consisted of 1257 hips: 221 with stage II, 220 with stage III, and 816 with stage IV. All patients were followed for a minimum of 2 years. The end point for failure was conversion to total hip arthroplasty. The physician group demonstrated a high degree of postoperative compliance. The conversion rate to total hip arthroplasty was significantly lower in the physician group (6.25%) compared to the control group (20.6%). Outstanding postoperative compliance appears to be related to favorable outcomes. Further evaluation of failure in both groups may help better understand FH osteonecrosis and improved patient outcomes.     

Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head

Osteonecrosis is a disease with a wide-ranging etiology and poorly understood pathogenesis seen commonly in young patients. Various head-preserving procedures have been used for this disease to avert the need for total hip replacement. These include various vascularized and nonvascularized bone grafting procedures. We will describe the use of bone-grafting through a window at the femoral head-neck junction for the treatment of osteonecrosis of the femoral head. Bone morphogenetic protein (BMP)-enriched allograft was used to avoid donor site morbidity. Nineteen patients (21 hips) were followed up for a mean of 48 months (range, 36-55 months) after a bone grafting procedure in which the diseased bone was replaced by a bone graft substitute (combination of demineralized bone matrix, processed allograft bone chips, and a thermoplastic carrier). Eighteen of 21 hips (86%) were clinically successful at latest followup. Two of these patients have minimal radiographic progression (< 2 mm head collapse). This procedure is straightforward technically, led to low morbidity, and did not necessitate procurement of donor site bone graft. This procedure may be effective at avoiding or forestalling the need for total hip arthroplasty in young patients with early to intermediate stages of osteonecrosis of the femoral head.     

股骨头髓芯减压带旋髂深血管蒂髂骨骨瓣植骨治疗股骨头缺血性坏死

目的　探讨股骨头髓心减压带旋髂深血管蒂髂骨骨瓣植骨术治疗股骨头缺血坏死的疗效及手术适应证。　方法　 1995年 10月～ 2 0 0 0年 8月共进行 18例 (2 6髋 )股骨头髓心减压带旋髂深血管蒂髂骨骨瓣植骨术。根据Harris髋关节评分系统进行关节功能评价 ,根据ARCO分期分型系统进行影像学评价。　结果　随访 16例 2 3髋 ,平均 3 1 5个月。Harris评分由术前平均 61 7改善为随访时 76 0分。 13髋 (5 6% )随访时Harris评分 >80 0分 (内侧型 8髋 ,中央型 3髋 ,外侧型 2髋 ) ,根据ARCO分期分型系统进行分类随访时优良率 ,内侧型 80 % ,中央型 60 % ,外侧型 2 5 %。 8髋分期发生进展。塌陷及失败率内侧型 2 0 % ,中央型 40 % ,外侧型 75 %。　结论　股骨头髓芯减压带旋髂深血管蒂髂骨骨瓣植骨术适用于ARCO分期分型系统中ⅠA中央型、ⅠB内侧型、ⅡA中央型、ⅡB内侧型股骨头缺血性坏死 ,并具有良好的近、中期疗效。对坏死范围较大的股骨头不能防止病程的进展 ,但可缓解症状 ,延缓全髋关节置换的时间     

Osteonecrosis of the femoral head. A study of 101 hips treated with vascularized fibular grafting

BACKGROUND: The present study evaluates the minimum five-year results of vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purposes of the present study were to review the results of fibular grafting in a large series of patients and to determine the indications for this procedure. METHODS: Eighty-six patients (101 hips) were followed clinically for a minimum of five years (or until the time of death). The study group included fourteen Marcus-Enneking stage-2 hips, twenty-three stage-3 hips, and sixty-four stage-4 hips. Three patients (three hips) died from unrelated causes before the five-year evaluation, and two patients (two hips) died after the five-year evaluation. Radiographic assessment was performed with use of the Marcus-Enneking grading system, and clinical assessment was performed with use of the Harris hip-scoring system. The end point was conversion to total hip arthroplasty. Patient satisfaction was also assessed. RESULTS: Sixty-two hips (61%) survived until the time of the five-year follow-up, and forty-two hips (42%) survived until the time of the interview (at a median of eight years postoperatively). The average Harris hip score was 58 +/- 13 at the time of presentation and 80 +/- 15 at five years. Eight (57%) of the Marcus-Enneking stage-2 hips, sixteen (70%) of the stage-3 hips, and thirty-eight (59%) of the stage-4 hips survived for at least five years. Of the eighty-one living patients (including forty-one who had a successful outcome and forty who had had a failure), forty-six patients (including twenty-one who had a successful outcome and twenty-five who had had a failure) stated that they would undergo the procedure again. CONCLUSIONS: Vascularized fibular grafting may provide a chance for normal hip function in the intermediate or long term in carefully selected patients with osteonecrosis of the femoral head.     

改良吻合血管游离腓骨移植治疗股骨头缺血性坏死的手术技术

目的探讨改良的吻合血管游离腓骨移植治疗股骨头缺血性坏死的手术技术、临床疗效及其并发症。方法2000年10月～2004年8月，共治疗124例（139髋）股骨头缺血性坏死患者，男83例（93髋），女41例（46髋）；年龄16～57岁，平均36．4岁。其中创伤性49例（54髋），激素性29例（32髋），酒精性19例（21髋），特发性27例（32髋）。SteinbergⅡ期50髋，Ⅲ期71髋，Ⅳ期18髋，Harris评分平均分别为：79．3、69.3和58．4分。采用改良的游离腓骨切取技术，设计髋前小切口入路，并采用改良的坏死清理技术。记录手术时间、总出血量及切口长度。术后行X线摄片、Harris评分及并发症的评价。结果游离腓骨手术时间为10～30min，平均15min。总手术时间为80～120min，平均90min。髋部切口长为6～12cm，平均8cm。总出血量为100～300ml，平均200ml。术后并发症少，平均住院时间7d。患者随访6个月～3年8个月，其中随访1年以上65例（78髋）患者的X线片显示：62髋（79．5％）的股骨头坏死有不同程度改善，14髋（17.9％）无明显变化，2髋（2．6％）恶化。Harris评分平均为：Ⅱ期94.4分，Ⅲ期86.0分，Ⅳ期74．1分。术后10例出现股前外侧皮肤麻木和感觉减退，1例小腿伤口延迟愈合，6例足背感觉异常，5例出现一过性供体肌力减弱，3例踝关节活动不适，但均未对日常生活产生明显影响。结论改良的吻合血管游离腓骨移植术具有出血少、解剖清晰、操作简便，创伤小，并发症少及术后功能恢复较好等优点，是治疗股骨头缺血性坏死的一种有效的保头治疗方法。     

The use of postoperative bone scintigraphy to predict graft retention

BACKGROUND: Osteonecrosis of the femoral head commonly occurs in patients aged under 50 years. Because of a high rate of complications associated with joint replacement surgery in this population, surgical techniques, such as vascularized fibular grafting, have been devised in an attempt to salvage the femoral head. The purpose of this study was to investigate the use of bone scintigraphy to predict graft retention after vascularized fibular grafting for osteonecrosis of the hip. METHODS: We evaluated single photon emission computed tomography images from 104 subjects whose hips were treated with vascularized fibular grafts between 1994 and 2000. We compared the signal intensity of the graft with the intensity of the ipsilateral proximal femoral diaphysis and assigned a score of 1 if less than diaphysis, 2 if equal to diaphysis and 3 if greater than diaphysis. We defined graft failure as conversion to or on the waiting list for total hip arthroplasty. RESULTS: Thirty percent of hips failed treatment (n = 31, mean graft survival 34.9 mo), while 70% of grafts were retained (n = 73, mean follow-up 56.6 mo). Bone scan scores were significantly lower in the failed group (mean 7.1, range 6-12), compared with the retained group (mean 8.5, range 6-18; p = 0.03). Logistic regression demonstrated that a bone scan score > 6 was associated with graft retention (p = 0.028), with an odds ratio of 3.08 (range 1.13-8.40). CONCLUSION: These results suggest that having a well-perfused graft in the early postoperative period improves the chances of graft retention in the future.     

Heterotopic ossification after treatment of femoral head osteonecrosis with free vascularized fibular graft

This study evaluated patients with heterotopic ossification after implantation of a free vascularized fibular graft for the treatment of femoral head osteonecrosis. We hypothesized that the osteogenic tendency of these patients might enhance the graft-host union and new bone formation in the femoral head, although the presence of heterotopic ossification might influence adversely the clinical result. Of patients with femoral head osteonecrosis, 32% developed heterotopic ossification after treatment with free vascularized fibular graft. Heterotopic bone formation did not influence the efficacy of the procedure to preserve the hip joint. The radiographic and clinical results and the rate of subsequent total hip arthroplasty were not affected by the heterotopic bone, but local trochanteric tenderness was associated with large heterotopic lesions.     

Results of free vascularized fibular grafting for femoral head osteonecrosis in patients with systemic lupus erythematosus

Osteonecrosis of the femoral head is a known complication of systemic lupus erythematosus.Patients often require surgical intervention at an early age. Options include total hip arthroplasty, core decompression, and free vascularized fibular grafting. Because these patients are usually young, any procedure that avoids total hip arthroplasty, especially if it does not make joint replacement more difficult, would be most desirable. Free vascularized fibular grafting is an effective method of treating osteonecrosis of the femoral head. Inpatients with lupus erythematosus, results of free vascularized fibular grafting at a minimum 2-year follow-up are similar to those in patients without a diagnosis of lupus.     

吻合血管游离腓骨移植治疗股骨颈陈旧性骨折及骨不连

目的评价吻合血管的游离腓骨移植术治疗股骨颈陈旧性骨折和骨不连的临床疗效。方法2000年11月至2005年12月采用吻合血管的游离腓骨移植术治疗29例股骨颈陈旧性骨折或骨不连患者,平均随访时间28．5个月,对患者的临床资料进行回顾性分析。结果术后所有患者均未出现严重手术并发症。患者均获得骨折愈合,骨折愈合时间4～6个月,平均5．6个月。除1例患者术后1年并发股骨头坏死,2年后置换人工关节,其余28例患者在随访期间内髋关节功能良好,Harris评分达88．2分,治愈率达96,3％。结论吻合血管的游离腓骨移植术是治疗股骨颈陈旧性骨折和骨不连的有效方法。     

SAS Weekly Rounds: Avascular Necrosis

Osteonecrosis of the femoral head is a condition that affects upwards of 10,000 individuals in the USA each year. The peak incidence is in the fourth decade of life, and overall, there is a male preponderance. The condition accounts for up to 12% of total hip arthroplasties performed in developed countries. The etiology can be traumatic or non-traumatic, with 90% of atraumatic cases attributed to corticosteroid therapy or excess alcohol consumption. Osteonecrosis of the femoral head reflects the final common pathway of a range of insults to the blood supply and ultimately results in femoral head collapse, acetabular involvement, and secondary osteoarthritis. Currently, conservative treatment options, which aim to correct pathophysiologic features allowing revascularization and new bone formation, appear to be able to delay but not halt the progression of this condition. As a consequence of femoral head osteonecrosis, many individuals undergo surgical treatments including: core decompression, osteotomy, non-vascularized bone matrix grafting, free vascularized fibular grafts, limited femoral resurfacing, total hip resurfacing, and total hip arthroplasty.     

吻合血管游离腓骨移植治疗股骨头坏死的系统回顾

目的通过综合分析关于吻合血管游离腓骨移植治疗股骨头坏死相关文献,探讨其疗效及安全性。方法系统检索自1980—01—2013—05吻合血管游离腓骨移植治疗股骨头坏死相关文献,按照纳入标准和剔除标准进行筛选,提取需要数据,通过循证医学分析方法,加权汇总分析。结果共检索出96篇相关文献,共10篇被纳入分析,共553例（656髋）,男426例,女127例,加权平均年龄（37．08±5．10）岁,加权平均随访时间（7．91±4．20）年。术后加权平均髋关节功能Harris评分（82．57±5．78）分较术前（62．69±10．07）分明显提高,差异有统计学意义（t=63．30,P〈0．05）。纳入文献中6篇（373髋）中78髋术后进展至髋关节置换,加权平均进展至髋关节置换时间为术后（5．96±2．51）年,术后髋关节幸存率79％。并发症主要深静脉血栓（6．60％）、拇趾趾问关节伸直功能受限（6．51％）、腓神经麻痹（3．76％）、术后感染（3．74％）、异位骨化（1．54％）、股骨粗隆部滑囊炎（1．00％）。结论吻合血管游离腓骨移植是一种治疗股骨头坏死安全有效的手术方法．但需要重视术后并发症问题。     

Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: Results from a series of 407 cases

The goal for treatment of osteonecrosis of the femoral head (ONFH) is to relieve pain, preserve the contour of the femoral head, and delay the need for total hip arthroplasty. The free vascularized fibular grafting (FVFG) has been shown to support the subchondral architecture as well as restore local circulation for the necrotic femoral head in treatment of ONFH. This report aimed to present the clinical results of the use of a modified surgical technique of FVFG for treatment of ONFH. Four hundred and seven patients with 578 hips of ONFH were included. The patients' average age was 36.7 years old (ranging 19–55 years old). The disease was staged from II to V based on the Steinberg classification system. By the modified procedure, the vascularized fibular graft was harvested via a lateral incision with fibular osteotomy prior to the exposure of the vascular pedicle, and the removal of necrotic tissue and inset of graft were performed through an anterior approach. The operative time averaged 90 min for unilateral ONFH (ranging 75–110 min) and 190 min for simultaneous treatment of bilateral ONFH (ranging 160–230 min). The average length of follow‐up was 5.0 years (ranging 3–10 years). The complications included one infection in one case, temporary loss of sensation of the thigh in eleven cases, and restricted motion of the great toe in nine cases. The Harris hip score of patients improved from 65.0 to 86.9 on average. Radiographic evaluation showed no changes in 331 hips (57.3%), improvement in 195 hips (33.7%) and necrosis progression in 52 hips (9.0%). Twenty‐three hips (4.0%) in 20 patients had total hip arthroplasty during the period. These results show that the modified technique of the use of FVFG for treatment of ONFH yields similar postoperative results in comparison to the traditional method. © 2013 Wiley Periodicals, Inc. Microsurgery 33:646–651, 2013.     

Uncemented total hip arthroplasty in patients with aseptic necrosis of the femoral head and previous bone grafting

Tibial strut bone grafting and more recently fibular strut grating (vascularized) have been used in the treatment of aseptic necrosis of the femoral head. The authors evaluated the technical aspects and results of uncemented total hip arthroplasty after previous tibial bone grafting of the femoral head in patients with aseptic necrosis. Review of postoperative radiographs demonstrated that residual tibial graft prevented optimal femoral canal fit and positioning of the prosthetic stem in 10 of 13 hips (in the coronal plane). In the nine hips with a minimum 2-year follow-up period, two required revision for loosening of the femoral component. The authors recommend that, when performing an uncemented total hip arthroplasty in patients with previous strut grafting, special attention be directed to adequate graft removal, particularly in the lateral greater trochanteric fossa to prevent varus placement of the femoral component. An intraoperative anteroposterior radiograph with the final femoral broach in place may be useful in verifying adequate strut graft removal and optimal canal fill with proper prosthesis positioning.