Free Vascularized Fibular Grafting for the Treatment of Postcollapse Osteonecrosis of the Femoral Head

• Published in: Journal of bone and joint surgery. American volume Vol. 86 SUPPLEMENT 1; pp. 87 - 101
• Main Authors: ALDRIDGE, J MACK, BEREND, KEITH R, GUNNESON, EUNICE E, URBANIAK, JAMES R
• Format: Journal Article
• Language: English
• Published: Copyright by The Journal of Bone and Joint Surgery, Incorporated 2004
• ISSN: 0021-9355; 1535-1386
• DOI: 10.2106/00004623-200400001-00012

BACKGROUND:Osteonecrosis of the femoral head, a disease primarily affect ing young adults, is often associ ated with collapse of the articular surface and subsequent arthro sis. 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 fibu lar grafting, between 1989 and 1999, for the treatment of os teonecrosis 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 to tal hip arthroplasty as the failure end point, and we analyzed the con tribution, to failure, of the size of the lesion, amount of preoperative collapse of the femoral head, etiol ogy 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 suc ceeded; 63% of the patients in that group had a good or excellent re sult. There was a significant rela tionship between the outcome of the grafting procedure and the etiol ogy of the osteonecrosis (p = 0.017). Patients in whom the os teonecrosis 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 arthro plasty with increasing lesion size and amount of collapse. Neither pa tient age nor bilaterality significantly affected outcome. CONCLUSIONS:Patients with postcollapse, prede generative osteonecrosis of the femoral head appear to benefit from free vascularized fibular graft ing, with good overall survival of the joint and significant improve ment in the Harris hip score. The results of this femoral head-pre serving procedure in patients with postcollapse osteonecrosis are su perior to those of core decompres sion and nonoperative treatment, as reported in the literature. Pa tients with larger lesions and cer tain diagnoses, such as idiopathic and alcohol-related osteonecrosis, have worse outcomes.