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
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.