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1、TREATMENT OF FEMORAL HEAD NECROSIS WITH FREEVASCULARIZED FIBULA GRAFTING:A PRELIMINARY REPORTCHANGQING ZHANG,M.D.,*BINGFANG ZENG,M.D.,ZHENGYU XU,M.D.,WENQI SONG,M.D.,LEI SHAO,M.D.,DONGXU JING,M.D.,and SHUPING SUI M.D.Since October 2000,56 hips in 48 patients with avascular necrosis of the femoral he
2、ad were treated with free vascularized fibular transplants.The average follow-up was about 16 months.The Harris hip scores of all stages were improved during follow-up.Most femoral heads showedimprovement(39 hips,69.6%)or were at least unchanged(14 hips,25.0%)on X-rays.The results show that a free v
3、ascularized fibular graftwould be a valuable procedure for femoral head necrosis.By this method,we can avoid or delay progress of the disease,and improve thefunction of the hip and quality of life.2005 Wiley-Liss,Inc.Microsurgery 25:305?309,2005.Since October 2000,56 hips in 48 patients with avas-cu
4、lar necrosis of the femoral head were treated with freevascularized fibula grafts in our hospital,and were fol-lowed up for an average time of about 16 months.Mostof them showed good results.CLINICAL MATERIALSince October 2000,56 hips in 48 patients with avas-cular necrosis of the femoral head were
5、treated with freevascularized fibula grafts in our hospital.They were as-sessedpostoperatively,withfollow-uprangingfrom8?30months(mean,16 months).There were 29 male patients(34 hips)and 19 female patients(22 hips).The mean agewas 37.3 years(range,22?55 years).Eight patients(5male and 3 female)had bi
6、lateral femoral head necrosis.Associated etiologic factors included:trauma(21 pa-tients,21 hips);steroid use(14 patients,18 hips);alcohol(2 patient,4 hips);and idiopathic(11 patients,13 hips).Our diagnosis was based on imaging modalities,including plain anteroposterior(AP)radiographs andmagnetic res
7、onance imaging(MRI).Preoperative mag-netic resonance images of the hips,used to confirm thesize of the lesion,were available for some patients.Somepatients had metal implants and were not allowed toundergo MRI examination,so MRI results were notused in these cases.Staging of lesions was based onStei
8、nberg staging.1According to the Steinberg classifi-cation,9 hips were in stage II(16.1%);16 hips were instage III(28.6%);and 31 hips were in stage IV(55.3%).Indications for the operation were all patients with painor disfunction of the hip,younger than age 55 years andwith Steinberg II,III,IV lesion
9、.Clinical evaluation was based on the presence ofpain and the functional outcome assessed by Harris hipscore.Radiologic examination and comparison withradiographs obtained before surgery revealed the fate ofthe femoral head and hip after treatment.Operative ProcedureThe patient is placed in supine p
10、osition.The hip andbilateral legs are prepared and draped as a single sterilefield.A sterile tourniquet is placed on the contralateralthigh.The approach to the hip is through the Smith-Peterson incision.After the fascia lata is incised,theinterval of the tensor fasciae latae and sartorius is ex-pose
11、d.The straight head of the rectus femoris is cut 1 cmto the anterior inferior iliac spine,where the rectusfemoris is attached.At the anterior margin of the ace-tabulum,the reflected head of the rectus femoris is alsocut.After the rectus femoris is turned over,the lateralfemoral circumflex artery and
12、 vein are identified toserved as recipient vessels.After dissection of the recipient vessels is completed,the anterior hip capsule is incisied longitudinally toachieve resection of the proliferative inflamed synovialtissue and pannus.Then a tunnel is made at the anterioraspectofthefemoralneckbybonec
13、hisel.Itswidthshouldbe similar to that of the grafted fibula.An additional ca-nal,which is made from the great tuberosity face to thefemoralhead,ismadewithadrillof0.4cmdiameter.Howtoremovethenecroticboneisaveryimportantpartoftheprocedure.Under fluoroscopic control,through thetunnelandcanal,with theh
14、elpofspecial instruments,thenecrotic bone in the femoral head is excised.The necroticbone must be excised asfar as possible.Usually itextendsto within 3?5 mm beneath the articular surface.The cancellous bone graft is then harvested from theiliac bone to fill up the cavity of the femoral head.TheDepa
15、rtment of Orthopedic Surgery,Shanghai Sixth Peoples Hospital,Jiao-tong University,Shanghai,China*Correspondence to:Changqing Zhang,Department of Orthopedic Surgery,Shanghai Sixth Peoples Hospital,600 Yishan Road,Shanghai 200233,China.E-mail:ZReceived 10 May 2004;Accepted 15 October 2004Published onl
16、ine 4 May 2005 in Wiley InterScience().DOI:10.1002/micr.20118 2005 Wiley-Liss,Inc.10982752,2005,4,Downloaded from https:/ by Shanghai Jiao Tong University,Wiley Online Library on 29/01/2023.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the app
17、licable Creative Commons Licensegrafted fibula is placed in the tunnel,after being clipped(thevesselsshouldbeplacedattheanterioraspect).Againunder fluoroscopic control,the position of the fibulashould be adjusted to buttress the articular surface.Thegraft fibula is stabilized to the femoral neck wit
18、h atitanium or absorbable screw(this does not interfere withfuture MRI examinations).Under an operating micro-scope,arterial and venous anastomoses are performedwith 6-0 interruped nylon sutures.The Serrefine is takenoff after the anastomoses are finished.Bleeding from thecortical bone at the base o
19、f the fibular graft confirms thevascularity of the graft.Both incisions are closed in aroutinemannerafterirrigation.Adrainisputintothehipincision,and removed after 48 hr.If the patient hasnonunion of the femoral neck,an additional 1?2 lagscrews are used after the bone graft is finished.Theaverage ti
20、me of the operation ranges from 2.5?4 hr.We use intravenous antibiotics from 1 day before theoperation to prevent infection.Postoperatively,if thereare no symptoms of infection,antibiotics will be ad-ministered orally instead of intravenously.Prophylacticanticoagulation includes intravenous administ
21、ration of500 ml of low-molecular-weight dextran daily for 5 daysand oral administration of 300 mg of aspirin twice a dayfor 2 weeks,followed by 300 mg a day for 6 weeks afterthe operation.Patients are instructed to take postoperative bedrest.Patients are also told to avoid bearing weight onthe extre
22、mity for 6 months,after which they may bearpartial weight.During the next 3 months,the amount ofweight-bearing is gradually increased to full weight-bearing by 9 months.RESULTSRadiographic AssessmentRadiographic assessment was evaluated using threeclasses:1)improved,i.e.,the necrosis was healed andr
23、eplaced with new bone;2)unchanged,i.e.,no change orno progress in comparison with the preoperative state;and 3)worse,i.e.,the necrosis has progressed or col-lapsed.Of 56 hips,just 3(Steinberg IV)appeared worsein the most recent radiographs.Thirty-nine hips showedimprovement(69.6%),and the other 14 a
24、ppeared un-Figure 1.A:Tunnel was made at anterior aspect of femoral neck by bone chisel.B:Additional canal was made from great tuberosity face tofemoral head.C:Through tunnel and canal,necrotic bone in femoral head was excised.D:Grafted fibula was placed in tunnel,and arterialand venous anastomoses
25、were performed under operating microscope.306Zhang et al.10982752,2005,4,Downloaded from https:/ by Shanghai Jiao Tong University,Wiley Online Library on 29/01/2023.See the Terms and Conditions(https:/ Wiley Online Library for rules of use;OA articles are governed by the applicable Creative Commons
26、Licensechanged(25%).According to the staging,9 hips ofstaging II(100%),13 hips of staging III(81.2%),and 17hips of staging IV(54.8%)showed improvement;3 hipsof staging III(18.8%)and 11 hips of staging IV(35.5%)appeared unchanged;and 3 hips of staging IV(9.7%)appeared worse.Harris Hip ScoreIn our res
27、earch,we used the Harris hip score to eval-uatefunctionofthehip.Beforetheoperation,theaverageHarris Score was 80 points for patients with stage II;69points for patients with stage III;and 55 points for pa-tients with stage IV.In the most recent follow-up,theHarris scores had shown improvement at all
28、 stages:95points for patients with stage II;89 points for patientswith stage III;and 76 points for patients with stage IV.The increase in scores ranged from 11?13 points for pa-tients with stage II,15?24 points for patients with stageIII,and 13?34 points for patients with stage IV.ComplicationsOne h
29、ip showed signs of superficial infection.Oneincision showed delayed union.Transient weakness inmusclessuppliedbytheperonealnerveintwoextremities,persistent sensory abnormalities in twofeet,and one patient with discomfort in the ankle withactivity were also reported.All these signs did notaffect the
30、results during follow-up.Contracture of theFigure 2.A:Radiograph of 22-year-old man before operation.B:Radiograph of patient 6 months after operation.Left femoral headshowing no progression of collapse and demonstrating incorporationof the fibular graft and preservation of the joint space.Figure 3.A
31、:Radiograph of 46-year-old woman before operation.B:Radiograph of patient 12 months after treatment.Femoral Head Necrosis With Free Fibula Grafting307 10982752,2005,4,Downloaded from https:/ by Shanghai Jiao Tong University,Wiley Online Library on 29/01/2023.See the Terms and Conditions(https:/ Wile
32、y Online Library for rules of use;OA articles are governed by the applicable Creative Commons Licenseflexor hallucis longus,refracture of the femoral neck,discomfort of the other sites,and deep embolism didnot take place.DISCUSSIONMany techniques2?5were introduced to treat femo-ral head necrosis.Mos
33、t of them did not achieve satis-factory results.Free vascularized fibula grafting to treatfemoral head necrosis was reported in many studies withgood results in last two decades.The dates have shownthat free vascularized fibular grafting can prevent thefemoral head from collapsing and improve the hi
34、pfunction of the patients.The rationale6for free vascularized fibular grafts intreating femoral head necrosis is based on four aspects:1)decompression of the femoral head,which mayinterrupt the cycle of ischemia and intraosseous hyper-tention thought to contribute to the disease;2)excisionof the seq
35、uestrum that might inhibit revascularization ofthe head;3)support of the subchondral surface with thecortical strut and with the anastomosed vessels,so thatthe revascularization process can be enhanced;4)fillingthe defect of the femoral head with the osteoinductivecancellous bone graft,so as to indu
36、ce the growth ofosteoblast.In this research,we used Steinberg staging.This di-vides the progress of the disease into 6 stages.It alsodivides stages II?V into A,B,C substages according tothe extension of the necrotic lesion.The extension can becalculated on plain anteroposterior(AP)radiographs ormagn
37、etic resonance imaging(MRI).With this method,we can analyze the results of the operation more effi-ciency and facility.The Steinberg staging is veryimportant in making decisions about an operation.How to excise the necrotic bone as far as possible is avery important part of the procedure.It determin
38、es theresults of the operation.In our operation,we made atunnel at the anterior aspect of the femoral neck,com-bined with a canal at the great tuberosity.Through thesetwoways,necroticbonescanbeexcisedthoroughly,usingwith some special instruments.Before the fibula is plan-ted,the cancellous bone shou
39、ld be grafted to fill up thecavity in the femoral head.We used titanium or absorb-able screws to stabilize the fibula with the femoral neck.This allowed for MRI examinations during follow-up.By the time of their most recent follow-up evalua-tion,for all patients with pain preoperatively,the painhad
40、disappeared or at least remitted.All patients,eventhe patients whose hip appeared worse on radiographsand felt discomfort casually,did not need only drugs forpain.Now feel no discomfortable of the hip 10 monthssince our treatment.Most patients had full weight-bearing and took part in the daily activ
41、ities,and werenot limited by their disease.Only two patients wereslightly limited in long-distance walking.All patientswere satisfied with the operation,and had confidence inrecovery in the future.Through this research,we thinkthe severity of the disease is the only factor whichinfluences the result
42、s of our treatment.The etiology andage,sex of the patient are not related to the results.Thisconclusion is consistent with the other research.Though the improvement of hip condition showedon the radiographies was not as obvious as the im-provement of hip function showed in clinical.Duringfollow-up,o
43、nly 3 hips became worse.The hips whichhad shown improvement or were unchanged after theoperation made up 94.6%,while 88.0%of the hips whichbelonged to staging II,III showed improvement onfollow-up.These data indicate the good result of the freevascularized fibula grafting.On radiographic evalua-tion
44、,the dates of our research is good than related re-ports.During the operation,with the help of specialtools,necrotic bones can be excised more thoroughly.We think this is the reason for the difference.The results of our preliminary research indicate thata free vascularized fibular graft would be a v
45、aluableprocedure for femoral head necrosis.The key point ofthis technique is to excise all necrotic tissue of the fem-oral head,followed by successful vascularized fibulargrafting.By this method,we can avoid or delay theprocess of the disease,and improve the function of thehip and quality of life.RE
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47、rcom PG,Strafford B,Hosick WB,Corces A,Bands RE,Hartman KE.Core decompression with bone graftingforosteonecrosisofthefemoralhead.ClinOrthop2001;386:71?78.4.Gallinaro P,Masse A.Flexion osteotomy in the treatment ofavascular necrosis of the hip.Clin Orthop 2001;386:79?84.5.Xenakis TA,Gelalis J,Koukoub
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