Analysis of failures after vascularized fibular grafting in femoral head necrosis

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Subjects

In this prospective study, 16 femoral heads were obtained in a 12-year period from 14 patients with osteonecrosis who were initially treated with implantation of a free vascularized fibular graft and subsequently, after failure of the grafting procedure, with total hip arthroplasty. In all patients included in this study, the total hip arthroplasties were performed by the surgeon who performed the initial vascularized fibular grafting procedure. Patients were regularly followed and consented to

Vascular patency

In 14 of the 16 hips, the peroneal artery of the implanted fibular graft was found patent upon inspection at the time of the femoral neck osteotomy. Blood flowed from the patent artery of the graft after the femoral head was removed.

Articular surface

Gross inspection of the articular surface in all fresh specimens revealed three different modes of damage: partial collapse (superior, medial, and lateral), total collapse, or noncollapse. In seven specimens a significant superior-anterior medial and lateral portion

Discussion

The microvascular implantation of a fibular graft into the affected segment of the femoral head is aimed at replacing necrotic or partially devitalized bone, which has lost its mechanical integrity, with a viable core of bone to buttress the articular surface and subsequently prevent collapse. The healing potential of the vascularized cortical bone graft is augmented by morselized cancellous graft packed around the proximal end of the fibula beneath the subchondral plate. To allow fusion of the

Summary

The authors hypothesized that evaluation of graft–host bone interactions after failed vascularized fibular grafting of femoral head necrosis may elucidate the reasons of failure of the procedure and assist in defining its indications more accurately. Macroscopic and histomorphologic-histomorphometric evaluation was performed on 16 femoral heads with osteonecrosis that were retrieved during total hip arthroplasty, 13 to 114 months after the initial vascularized fibular grafting procedure. Three

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  • Cited by (24)

    • Hip Resurfacing After Failed Free Vascularized Fibular Graft

      2009, Journal of Arthroplasty
      Citation Excerpt :

      In all cases, the fibular graft was found at the time of hip resurfacing to have incorporated into the femoral head and neck distal to the area of articular surface collapse or fragmentation. As previously described in cases of failed vascularized fibular grafting, there was uniformly incomplete union of the bone graft tip with the subcondral bone, resulting in collapse of the osteochondral surface remnant [13]. Assessment of incorporation of the fibular strut with host bone was assessed by gross examination only; histologic analysis was not obtained to confirm union or the diagnosis of avascular necrosis.

    • Osteonecrosis of the femoral head: Etiology, imaging and treatment

      2007, European Journal of Radiology
      Citation Excerpt :

      The most commonly used procedures are rotational osteotomy, core decompression, and free vascularized fibular grafting. Factors affecting the outcome of these procedures include patient's age, etiology and stage of osteonecrosis, and size and location of the osteonecrotic lesion [58–72]. Preservation of the femoral head with osteonecrosis depends on prevention of collapse of the structurally compromised necrotic bone.

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