The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Osteonecrosis of the Femoral Head: A Study of 101 Hips Treated with Vascularized Fibular Grafting"
by Donn Marciniak, MD, Christopher Furey, MD, and John W. Shaffer, MD, et al.

Commentary & Perspective by
Marvin E. Steinberg, MD, and David R. Steinberg, MD*,
Department of Orthopaedic Surgery, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

In the April issue of The Journal, Marciniak et al. have reviewed the results of 101 hips with osteonecrosis treated with vascularized fibular grafting and followed for a minimum of five years. Survivorship was 61% at five years and 42% at final follow-up, a mean of eight years after surgery. Seventy percent of surviving hips had no or minimal limitation and 30% had moderate to severe limitation in day-to-day activities. The complication rate was low compared with other series¹. They correctly noted that their results were not as encouraging as other long-term studies^2-4 and believed that this might be due to differences in surgical technique. They concluded that this procedure "…potentially postpones the need for arthroplasty in young patients and offers the possibility of long-term benefits in [carefully] selected patients…"

The authors are to be complimented for a careful and candid study that provides useful information about the results of vascularized fibular grafting in the treatment of osteonecrosis. There are relatively few reports on this technique and it remains somewhat controversial. Even in experienced hands, this is not a simple procedure and results might not always be as good as some others have reported^2-4.

The authors stated that careful patient selection is needed to ensure the best possible outcome, yet they do not clearly define their indications for the procedure. They found no difference in outcome between hips treated before femoral head collapse and those treated after, in contradistinction to other studies^2-5. They apparently did not attempt to evaluate the effect of lesion size nor did they include hips with pre-radiographic lesions, as the staging system used did not include these parameters. Other studies have indicated that the prognosis for hips with small, early lesions, treated before femoral head collapse, is better than for those with larger or more advanced lesions^2,5. It is not entirely clear how the authors approached the patients with bilateral disease, which is present in over 50% of hips. Because fibular grafting requires up to six months of protected weight-bearing, it may be necessary to delay surgery on the contralateral hip for quite some time, thereby allowing the condition to progress and adversely affect the outcome.

The authors have cited several references confirming the poor prognosis for hips treated nonoperatively. They have also briefly alluded to other surgical procedures designed to retard progression and preserve the femoral head. However, they have not attempted to compare the results of these procedures with those obtained by fibular grafting. This would have been of interest. Others have reported satisfactory results with simpler, less invasive methods of treating osteonecrosis, such as core decompression or nonvascularized grafting procedures². This raises the question as to whether the results of vascularized fibular grafting are clearly and sufficiently superior to justify the performance of a more extensive and technically demanding procedure which is associated with a higher complication rate.

In the younger patient with osteonecrosis, it is certainly preferable to preserve rather than replace the femoral head when possible. Older studies of total hip replacement in patients with osteonecrosis have reported a high prevalence of early implant failure. However, recent reports with newer techniques and components have indicated a much better survivorship². Thus, surgeons are becoming less reluctant to perform total hip replacement, and perhaps other forms of arthroplasty, on younger patients with advanced stages of osteonecrosis. Both patients and surgeons would often prefer an established procedure with a low complication rate, a 95% incidence of good-to-excellent results, and a 90% chance of ten or more years of survivorship over a complicated procedure such as vascularized fibular grafting with a much less certain outcome.

We need additional, prospective controlled studies to compare the results of vascularized fibular grafting to other joint-preserving procedures. Specific indications for each should be more clearly defined. If vascularized fibular grafting is selected, it should be performed in centers with sufficient experience and expertise to yield optimum results.

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. Vail TP, Urbaniak JR. Donor-site morbidity with use of vacularized autogenous fibular grafts. J Bone Joint Surg Am. 1996;78:204-11.
2. Steinberg ME, Mont MA. Osteonecrosis. In: Chapman MW, Szabo RM, Marder R, Vince KG, Mann RA, Lane JM, McLain RF, Rab G, editors. Chapman's orthopaedic surgery, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 3263-308.
3. Sotereanos DG, Plakseychuk AY, Rubash HE. Free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. Clin Orthop. 1997;344:243-56.
4. Soucacos PN, Beris AE, Malizos K, Koropilias A, Zalavras H, Dailiana Z. Treatment of avascular necrosis of the femoral head with vascularized fibular transplant. Clin Orthop. 2001;386: 120-30.
5. Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003;85:987-93.