Abstract
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).
Level of Evidence: Therapeutic Level III. See
Instructions to Authors for a complete description of levels of evidence.
Untreated osteonecrosis of the femoral head generally results in a
progressive course of subchondral fracture, collapse, and painful disabling
arthrosis1,2.
The prognosis is influenced by the stage, size, and location of the lesion.
While the results of femoral head-preserving procedures, such as core
decompression3-5,
electrical
stimulation6,7,
transtrochanteric rotational
osteotomy8, and
vascularized and nonvascularized
bone-grafting9-14,
have been encouraging in hips with early-stage, small, medially located
lesions4,15,
the treatment of large lesions has been a challenge to orthopaedic surgeons.
The use of a vascularized fibular graft was initiated in an effort to enhance
revascularization and to arrest the progression of necrosis. Many authors have
reported good results with the
technique16-20.
The purpose of the present study was to compare the effectiveness of a
vascularized fibular graft with that of a nonvascularized fibular graft for
preventing collapse and progression of large osteonecrotic lesions in two
groups of patients who were matched according to the etiology, stage, and
extent of the lesion.
Selection of Patients and Procedure
Forty-four patients (fifty hips) with a large osteonecrotic lesion
of the femoral head underwent vascularized fibular grafting and twenty-four
patients (thirty hips) with a large osteonecrotic lesion of the femoral head
underwent nonvascularized fibular grafting at a single center from March 1998
to April 2000. Each patient selected the procedure that he or she preferred
after the surgeon (S.-Y.K.) had explained the potential advantages and
disadvantages of each procedure, as follows.
We do not know the effectiveness of vascularized fibular grafting when
compared with nonvascularized fibular grafting for the treatment of
osteonecrotic lesions of the femoral head.The potential advantages of vascularized fibular grafting are that it can
support both osteoinduction and osteoconduction because it is a viable bone
graft.The potential disadvantages of vascularized fibular grafting are that it
requires a longer operation, leaves a longer operative scar, and is associated
with more donor site morbidity such as ankle instability, toe-clawing,
subtrochanteric fracture, and heterotopic ossification.
We do not know the effectiveness of vascularized fibular grafting when
compared with nonvascularized fibular grafting for the treatment of
osteonecrotic lesions of the femoral head.
The potential advantages of vascularized fibular grafting are that it can
support both osteoinduction and osteoconduction because it is a viable bone
graft.
The potential disadvantages of vascularized fibular grafting are that it
requires a longer operation, leaves a longer operative scar, and is associated
with more donor site morbidity such as ankle instability, toe-clawing,
subtrochanteric fracture, and heterotopic ossification.
The selection of vascularized or nonvascularized fibular grafting was based
solely on the preference of the patient.
Nineteen patients (twenty-three hips) who had selected, and had undergone,
vascularized fibular grafting were retrospectively matched to nineteen
patients (twenty-three hips) who had undergone nonvascularized fibular
grafting. The matching was based on the stage, extent, and etiology of the
lesion; average age; and preoperative Harris hip score
(Table I).
The radiographic inclusion criterion was a Stage-IIC lesion (involvement of
>30% of the femoral head and dome depression of =2 mm), according to the
classification system of Steinberg et
al.21, or a larger
lesion. The stage of the lesion and the extent of involvement were assessed on
serial magnetic resonance imaging cuts. The dome depression was measured with
use of plastic templates with Mose concentric circles and digital calipers
(model CD-15; Mitutoyo, Kawasaki, Japan), with an accuracy of 0.01 mm.
Collapse was defined as any dome depression of >2 mm.
Follow-up clinical and radiographic examinations were performed every three
months for one year, every six months for three years, and annually
thereafter. The clinical result was graded as excellent when the Harris hip
score22 was =90
points, good when it was between 80 and 89 points, fair when it was between 70
and 79 points, and poor when it was <70 points.
Operative Procedure
With the patient in the supine position on a fracture table, a 5-cm
straight lateral skin incision was made and centered over the proximal femoral
metaphysis. The proximal margin of the incision was at the level of the vastus
lateralis ridge of the greater trochanter. The entry site of the core track
was located just proximal to the level of the lesser trochanter. The
iliotibial band was incised longitudinally, and the origin of the vastus
lateralis was elevated in a T-shape to expose the lateral portion of the
proximal part of the femur. For the nonvascularized fibular grafting, a 12 to
15-mm-diameter core was cut, under fluoroscopic control, with solid cutting
reamers (Zimmer, Warsaw, Indiana). The reamers were advanced to the center of
the lesion, within 5 to 10 mm of the subchondral plate of the femoral head.
For the vascularized fibular grafting, an 18 to 24-mm-diameter core was cut in
a sequential fashion. As much necrotic bone as possible was removed with a
curet and a low-speed burr (Zimmer), and a mushroom-shaped excavation of the
necrotic subchondral bone was performed under fluoroscopy. Local autologous
cancellous bone was carefully packed into the defect.
The nonvascularized graft was harvested from the ipsilateral leg, according
to the surgical technique described by
Phemister12;
inserted into the core; and fixed with a 1.5-mm Kirschner wire. Vascularized
grafting was performed with the surgical technique described by Yoo et
al.20. The patient
was placed in the prone position, and the incision was extended to the
inferior gluteal fold for dissection of the recipient vessels. In the loose
connective tissue between the biceps femoris and the vastus lateralis muscle,
the first or second perforating branch of the profunda femoris artery was
exposed. The second perforating branch is preferable because it is generally
larger and of greater diameter than the first. The vascularized fibula, with a
peroneal muscle cuff that included the periosteum and a buoy flap, was
harvested from the leg through a lateral approach, as described by Urbaniak et
al.16 and Gilbert
et al.19. The buoy
flap (Fig. 1), which was
vascularized by the circular periosteal vessels of the fibula, was made with
use of the skin overlying the vascularized fibula and was attached to the
lateral aspect of the proximal part of the thigh to monitor the vascular
patency of the fibular graft after the vessel was sutured. The vascularity of
the graft also was assessed with noninvasive color Doppler ultrasonography (at
ten days postoperatively), magnetic resonance angiography (at fourteen days
postoperatively), and bone scintigraphy (at ten days, three months, one year,
and two years postoperatively).
The vascularized graft was placed into the core and fixed with a 1.5-mm
Kirschner wire. An end-to-end anastomosis was performed, with two veins
sutured first. The hip muscles were closed loosely to avoid compression of the
vascular pedicle. We deemed the graft position to be optimal when the proximal
end of the graft was within 5 to 10 mm of the subchondral plate of the femoral
head. The ideal position was in the center of the femoral head as determined
by intraoperative fluoroscopy and by anteroposterior and lateral plain
radiographs made postoperatively.
The postoperative rehabilitation program was identical for the two groups.
The patient walked with toe-touch weight-bearing for three months and then
with partial weight-bearing for the subsequent three months. At six months, he
or she began full weight-bearing with a cane.
Statistical Analysis
Survivorship was calculated with the Kaplan-Meier method. The end point was
conversion to a total hip replacement. Statistical analysis was performed with
a Mann-Whitney U test and a Fisher exact test with use of SAS software
(version 6.12; SAS Institute, Cary, North Carolina) to assess the differences
in the Harris hip score, prevalence of collapse, and mean dome depression
between the two groups. Significance was set at p < 0.05.
The clinical and radiographic results are shown in
Table II. At the time of the
final follow-up, at a mean of four years, the mean Harris hip score of the
Stage-IIC hips treated with vascularized fibular grafting was significantly
better than that of the Stage-IIC hips treated with nonvascularized fibular
grafting (p < 0.05). The graft position was deemed to be optimal in all
hips. Four of the ten Stage-IIC hips treated with vascularized grafting had
radiographic signs of progression and one Stage-IIC hip in that group
collapsed. Of the ten Stage-IIC hips treated with nonvascularized grafting,
eight had radiographic signs of progression and five had collapsed. With the
numbers available, there was no significant difference in the rate of
radiographic progression or collapse between the two groups.
The two Stage-IIIC hips in each group showed radiographic signs of
progression. One of the two hips treated with vascularized grafting and both
hips treated with nonvascularized grafting had collapsed.
At the time of the final follow-up, the mean Harris hip score for the
Stage-IVC hips treated with vascularized grafting was significantly better (p
< 0.05) than that for the Stage-IVC hips treated with nonvascularized
grafting. Of the eleven Stage-IVC hips with a vascularized graft, seven showed
radiographic signs of progression and six of them had collapsed. Of the eleven
Stage-IVC hips with a nonvascularized graft, ten had radiographic signs of
progression and nine of them had collapsed. There was no significant
difference in the rate of radiographic progression or collapse between the two
groups.
When all hips in the two groups were compared at the time of the final
follow-up, the mean Harris hip score was found to be significantly better (p
< 0.05) and the rates of radiographic progression and collapse were found
to be significantly lower in the group treated with vascularized grafting (p
< 0.05) (Table II).
Overall, the mean Harris hip score improved for 70% (sixteen) of the
twenty-three hips treated with vascularized grafting; seven hips (30%) were
rated excellent, ten (44%) were rated good, two (9%) were rated fair, and four
(17%) were rated poor. The mean Harris hip score improved for 35% (eight) of
the twenty-three hips treated with nonvascularized grafting; three hips (13%)
were rated excellent, five (22%) were rated good, five (22%) were rated fair,
and ten (43%) were rated poor.
With the numbers available, there were no significant differences in
clinical results according to the etiology of the osteonecrosis in either
group. Additionally, there were no significant differences in the rates of
radiographic progression and collapse according to the etiology in either
group. The mean time to collapse was twenty-three months (range, five to fifty
months) for the Stage-IIC hips treated with vascularized grafting and
twenty-four months (range, four to forty-eight months) for those treated with
nonvascularized grafting. Overall, the mean dome depression was significantly
less in the hips with a vascularized graft (2.8 mm; range, 1 to 7 mm) than it
was in those with a nonvascularized graft (4.3 mm; range, 1 to 10 mm) (p =
0.02). The mean dome depression was 0.8 mm (range, 0 to 2 mm) in the Stage-IIC
hips treated with vascularized grafting and 2.6 mm (range, 0 to 4 mm) in those
treated with nonvascularized grafting.
The rate of conversion to total hip replacement was 13% (three of
twenty-three hips) in the vascularized graft group and 22% (five of
twenty-three hips) in the nonvascularized graft group. Total hip replacement
was performed twenty-two, twenty-four, and forty-eight months after the
vascularized grafting procedures and eighteen, nineteen, twenty-four,
thirty-three, and thirty-six months after the nonvascularized grafting
procedures. In the vascularized graft group, one hip that had initially been
Steinberg Stage IIIC and two that had been Steinberg Stage IVC were converted
to a total hip replacement. In the nonvascularized graft group, one Stage-IIC
hip, one Stage-IIIC hip, and three Stage-IVC hips were converted.
Kaplan-Meier survivorship analysis revealed a three-year survival rate of
91.3% (95% confidence interval, 85.4% to 92.2%) for the entire group of hips
treated with vascularized grafting and 78.3% (95% confidence interval, 69.7%
to 86.9%) for the entire group treated with nonvascularized grafting
(Fig. 2). There was no
significant difference in the three-year survival rate between the two groups
(p > 0.05).
Complications
Clawing of the great toe or other toes occurred in three patients treated
with vascularized grafting, and a sensory peroneal neuropathy occurred in
three others in that group. The sensory neuropathy resolved spontaneously
within two years in two patients. A sensory peroneal neuropathy occurred in
one patient treated with nonvascularized grafting. It resolved by one year
postoperatively. No patient treated with nonvascularized grafting had clawing
of the toes.
The color of the buoy flap changed to bluish in two of the fifty hips (in
forty-four patients) that underwent vascularized grafting for a large
osteonecrotic lesion of the femoral head at our institution. However, one hip
had arterial patency as demonstrated by Doppler signal ultrasonography and
magnetic resonance angiography, and that hip was included in the vascularized
graft group (before matching). An obstruction of the anastomosed artery
developed in the other hip, as demonstrated by the absence of a Doppler
ultrasound signal and also by magnetic resonance angiography. That case was
assigned to the nonvascularized graft group (before matching). However, these
two hips were not included among the twenty-three hips treated with
vascularized grafting or the twenty-three treated with nonvascularized
grafting that had been selected for comparison in the present study.
The use of a nonvascularized bone graft, as originally described by
Phemister12, has
had variable success in the treatment of osteonecrosis. Marcus et
al.23 reported
satisfactory clinical results in seven of eleven hips at the time of
short-term follow-up (range, two to four years). Dunn and
Grow24 reported
only four good results in twenty-three patients treated with nonvascularized
bone-grafting. Nelson and
Clark25 treated
fifty-two hips with Phemister bone-grafting and concluded that the technique
is not effective once collapse has occurred. Boettcher et
al.9 reported
success in twenty-seven (71%) of thirty-eight hips six years after
nonvascularized tibial strut grafting. However, in a longer-term evaluation
(performed at a mean of fourteen years postoperatively) that included the
original thirty-eight hips in the study by Boettcher et al., Smith et
al.14 found that
only sixteen (29%) of fifty-six hips still had a good result.
There have been several reports of successful results with the use of
vascularized fibular
grafting16-20,26.
Yoo et al.20
reported the clinical and radiographic results in seventy-four of eighty-one
hips at a minimum of three years postoperatively. Seventy-two hips (89%)
showed radiographic improvement. Urbaniak et
al.16 evaluated the
effects of vascularized fibular grafting in a group of 103 hips followed for a
minimum of five years; total hip arthroplasty was performed in two of nineteen
hips with disease classified as Stage II according to the system described by
Marcus et al.23,
five (23%) of twenty-two hips with Stage-III disease, and seventeen (43%) of
forty hips with Stage-IV disease. Eighty-one percent of the patients were
satisfied with their decision to have vascularized fibular grafting.
Sotereanos et al.18
reported the results of vascularized fibular grafting in a group of
eighty-eight hips followed for a minimum of three years; 58% of the hips with
Steinberg Stage-IIC disease and 40% of those with Steinberg Stage-IIIC disease
had an excellent or good result. Kane et
al.26 compared the
results of vascularized fibular grafting with those of core decompression for
the treatment of femoral head osteonecrosis (Ficat Stage II or III) in a group
of forty patients followed for a minimum of two years. They concluded that
vascularized fibular grafting had significantly better results (p <
0.05).
We are aware of only one report comparing the clinical results of
vascularized fibular grafting with those of nonvascularized fibular grafting
for femoral head
osteonecrosis27.
Plakseychuk et
al.27 evaluated the
results of vascularized fibular grafting (220 hips) and nonvascularized
fibular grafting (123 hips) in a retrospective cohort study from two
institutions in different countries. They matched fifty hips by the stage,
size, and etiology of the lesion and by the mean preoperative Harris hip
score, and they reported the results at a minimum of three years
postoperatively. The mean Harris hip score improved for 70% of the hips
treated with vascularized fibular grafting and 36% of the hips treated with
nonvascularized fibular grafting. The seven-year rate of survival of the
Stage-I and II hips (precollapse) was 86% after treatment with vascularized
fibular grafting compared with 30% after nonvascularized fibular grafting. The
authors concluded that vascularized fibular grafting is associated with better
clinical and radiographic results, especially when it is performed prior to
collapse of the femoral head.
The present study has strengths compared with the study by Plakseychuk et
al.27. We performed
a closely matched prospective study in which vascularized fibular grafting and
nonvascularized fibular grafting were done in parallel by the same surgeons at
the same institution. Also, there were no differences in ethnicity or social
or economic status between the groups. The patency of the artery was evaluated
with assessment of a buoy flap and with several noninvasive methods, rather
than with invasive direct angiography as it was in the study by Plakseychuk et
al.
The present study suggests a possible reason why the vascularized fibular
grafting had better clinical and radiographic results than the nonvascularized
fibular grafting. The hips treated with vascularized fibular grafting seemed
to have less dome depression of the femoral head postoperatively. We suggest
that retention of head sphericity might be associated with a more rapid
induction of primary callus formation in the subchondral bone as a result of
more robust revascularization and increased osteoinductive potential of the
vascularized graft.
The present study strongly suggests that vascularized fibular grafting is
associated with better clinical and radiographic results than is
nonvascularized fibular grafting in precollapse hips, particularly those with
Steinberg Stage-IIC disease. However, large randomized, prospective controlled
trials comparing the efficacy of these two treatment modalities in hips with
later stages of osteonecrosis are needed.
Note: The authors thank Dr. Kyung-Rak Sohn for the pathologic
analysis and Dr. Jong-Min Lee for the radiographic interpretation.
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