The Knee: Reconstruction, Replacement  and Revision Tracking Pixel
Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

FVFG: Surgical Technique

- Discussion: 
- Fibular Harvest:

- Hip Preparation: 
Various methods have been advocated for the treatment of acascular necrosis of the hip in the young patient. From the literature an operative treatment for the symptomatic hip is the conservative method of management. Reports on core decompression, osteotomies, electrical stimulation, and bone grafting have been difficult to interperate. There are few prospective controlled studies in the literature. Vascularized bone grafting has had the most consistent successful results. Morbidity of the donor site is minimal and the time for the operation is comparable to that for a total hip arthroplasty. The graft does have a longer rehabilitation time and does not afford as complete pain relief as a total hip arthroplasty. When compared to a total hip arthroplasty the vascularized fibular graft has several advantages. The presence of a fibular graft does not preclude the later conversion to a total hip arthroplasty, and the operation is easier than after hip osteotomies, and certainly a much more desirable operation than an early hip revision. There is no increased risk of infection. If the procedure is done before collapse there is a chance that the graft will be viable for the life of the patient. Extracapsular free vascularized fibular grafting is the treatment of choice for AVN of all grades in the young patient at our institution. The graft, theoretically, treats many of the ongoing processes of osteonecrosis. It allows decompression of the femoral head in an effort to halt the ischemia due to increased interosseous pressure. Necrotic bone which can inhibit healing is removed and replaced with cancellous bone which has osteoinductive and conductive factors. The cortical strut supplies a basis of reinforcement for the subchondral bone and the vascular pedicle guarantees a supply of nutrients and blood to the healing femoral head. Medium term follow up has indicated that the procedure has proven its efficacy for almost all grades of osteonecrosis of the hip.


 - references: 
- Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment.
- Structural Bone-Grafting for Early Atraumatic Avascular Necrosis of the Femoral Head.
- Vascularized fibular grafting compared with core decompression in the treatment of femoral head osteonecrosis.  
- Results of transtrochanteric rotational osteotomy for femoral head osteonecrosis
- Indications and results of intertrochanteric osteotomy in osteonecrosis of the femoral head
- A finite-element analysis of the effects of intertrochanteric osteotomy on stresses in femoral head osteonecrosis
- Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results
- Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results
- Intertrochanteric osteotomy and autogenous bone-grafting for avascular necrosis of the femoral head
- Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips
- Osteonecrosis of the femoral head. Hip salvaging with implantation of a vascularized fibular graft
- Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head
- Transfer of vascularized grafts of iliac bone to the extremities
- Prevention of ankle valgus after vascularized fibular grafts in children. 

Additional References 
Nontraumatic necrosis of bone (osteonecrosis).
Uncemented total hip arthroplasty in patients less than 45 years with avascular necrosis.  
Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. 
Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head.
Free microvascular fibular transfer for idiopathic femoral head necrosis: long-term follow-up. 
Core decompression for femoral head necrosis. Prospective study of 28 patients. 
Femoral neck fractures in young adults.  
Idiopathic necrosis of the femoral head in adults
Results of conservative management of osteonecrosis of the femoral head. A retrospective review.
The natural history of the silent hip in bilateral atraumatic osteonecrosis.  
Results of core decompression for femoral head osteonecrosis.  
Osteonecrosis of the femoral head: A prospective randomized treatment protocol.  
Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment.  
Core decompression for early atraumatic osteonecrosis of the femoral head.  
Core decompression in femoral head osteonecrosis. 18 Stage I hips followed up for 1-5 years. 
The etiology of steroid-induced avascular necrosis of bone. A laboratory and clinical study. 
Alcoholism associated ischemic necrosis of the femoral head. Early diagnosis and treatment. 
A cross study evaluation of association between steroid dose and bolus steroids and avascular necrosis of bone.  
Alcoholism, hypercortisonism, fat embolism and osseous avascular necrosis. 1971. 
Pathological review of osteonecrosis in divers.  
A microangiographic study of idiopathic osteonecrosis of the femoral head. 
Early arteriopathy and postulated pathogenesis of osteonecrosis of the femoral head. The intracapital arterioles. 
Necrosis of the femoral head associated with sickle-cell anemia and its genetic variants. A review of the literature and study of thirteen cases. 
Hypofibrinolysis: a common, major cause of osteonecrosis. 
Non-traumatic avascular necrosis of the femoral head. 
The conserveative treatment of osteonecrosis of the femoral head. A comparison of core decompression and pulsing electromagnetic fields
Osteonecrosis of the femoral head treated by pulsed electromagnetic fields (PEMFs): a preliminary report. 
Success of core decompression in the management of early stages of avascular necrosis: a four year prospective study. Robinson HJ, Edwards D. Orthop Trans 1992-1993;16:707. 
Early results in the treatment of avascular necrosis of the femoral head with electrical stimulation.  
The effect of electrical stimulation on osteonecrosis of the femoral head.  
Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. 
Rotational osteotomy for non traumatic avascular necrosis of the femoral head
Intertrochanteric osteotomy and autogenous bone grafting for avascular necrosis of the femoral head.  
Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. 
Overview of attempts to revitalize the dead head in aseptic necrosis of the femoral head--osteotomy and revascularization. 
Indications and results of intertrochanteric osteotomy in osteonecrosis of the femoral head.  
Total hip replacement after upper femoral osteotomy. A clinical review. 
Treatment of the necrotic head of the femur in adults. 
Aseptic necrosis of the femoral head and nonunion of the femoral neck. Effect of treatment by drilling and bone grafting (Phemister technique).  
Structural bone grafting for early atraumatic avascular necrosis of the femoral head.  
Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis.
Fresh autogenous grafts and osteochondral allografts for the treatment of segmental collapse in osteonecrosis of the hip.  
Leung P-C. Use if the vascularized pedicle iliac crest graft in treatment of ischemic necrosis of the femoral head. In: Microsurgery for Major Limb Reconstruction, Urbaniak, JR (ed). St Louis, CV Mosby, pp 200-204, 1987. 
The treatment of osteonecrosis with fresh osteochondral grafts and with the muscle pedicle graft technique.  
Treatment of osteonecrosis of the femoral head by drilling and muscle-pedicle bone grafting.




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, May 23, 2012 11:55 am