Commentary & Perspective

Commentary & Perspective on
"Vascularized Compared with Nonvascularized Fibular Grafts for Large Osteonecrotic Lesions of the Femoral Head"
by Shin-Yoon Kim, MD, et al.

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

The treatment of nontraumatic osteonecrosis of the femoral head continues to be one of the more challenging problems in orthopaedics. Without specific treatment, most lesions will progress, and, eventually, the patient will require arthroplasty. Since this condition occurs primarily in young adults, our goal is to preserve rather than replace the femoral head whenever possible. Although a number of surgical procedures are available, none is entirely satisfactory and there is no general consensus as to which procedure is best.

Free vascularized fibular grafting is a technically difficult procedure that requires specialized training and expertise, is costly and time-consuming, requires a long period of recovery, and has a relatively high prevalence of complications^1-4. Although the reported results have varied, proponents feel that this procedure is superior to most other surgical approaches^1-5. One of its major advantages is believed to be the direct and immediate introduction of a viable, vascularized graft into a necrotic region of the femoral head, thus enhancing the healing process. Others have suggested that surgical decompression, excision of necrotic bone, and grafting without the need to perform a vascular anastomosis might yield equally gratifying results and would simplify the procedure considerably as well as reduce the relatively high prevalence of complications^3,5.

Animal studies have suggested that vascularized grafts are more effective than nonvascularized grafts⁶. Plakseychuk et al. in 2003 compared vascularized to nonvascularized fibular grafting in patients with osteonecrosis of the femoral head⁵. They concluded that better results were achieved with vascularized grafts in hips treated before femoral head collapse, as determined by Harris hip scores and radiographic progression. No significant differences were noted in hips that were treated after collapse, and poor results were noted in both groups. Unfortunately, the two groups were not entirely comparable because all vascularized grafting was performed in the United States and all nonvascularized grafting was done in Korea. Hence, the strength of their conclusions was limited by many possible variables, including differences in population demographics, surgical techniques, methods of evaluation, and indications for total hip replacement.

The present study sought to eliminate these variables by evaluating patients treated in parallel by the same surgeons at one center in a prospective, case-controlled study. Both precollapse (Stage II) and postcollapse (Stages III and IV) hips were included, but only hips with large (Stages IIIC and IVC) lesions were evaluated. The authors found that in general, hips treated with vascularized fibular grafts did better than those treated with nonvascularized grafts. However, the difference was significant only with precollapse (Stage II) hips and was less apparent in hips treated after collapse (Stages III and IV), in which the outcome for both groups was relatively poor. In Stage III and IV hips, nine of thirteen with vascularized grafts underwent progression, and in seven femoral heads the collapse was >2 mm. This study included twenty-three hips in each group with a mean four-year follow-up. The difference in results in Stages III and IV hips might have reached statistical significance had more patients with a larger follow-up been available. Complications occurred predominantly in the vascularized group, with clawing of the toes in three patients and a sensory peroneal neuropathy in another three. Only one complication (a sensory peroneal neuropathy) was reported for the nonvascularized group.

The authors concluded that this study strongly suggested that vascularized fibular grafting is associated with better results than nonvascularized grafting, particularly in precollapse hips with large lesions. They cautioned that larger, randomized, prospective controlled studies were needed to compare these two different techniques in patients with later stages of osteonecrosis.

Basically, I agree with their conclusions.

The authors are to be congratulated for performing a badly needed study in an attempt to determine whether a vascularized graft would yield better results than a nonvascularized graft. To date, this remains a subject of debate. It is important that they evaluated hips with large lesions, since it is recognized that large lesions are the most difficult to treat effectively regardless of the technique used. Their finding, that hips treated before collapse have a better outcome than hips treated after collapse, supports the findings of previous studies of free vascularized fibular grafting^1,3-5.

This study did not attempt to compare directly the results of fibular grafting with those of other techniques for treating osteonecrosis of the femoral head. We are therefore still left with the question as to what are the indications for free vascularized fibular grafting. Under what circumstances are the results of free vascularized fibular grafting sufficiently superior to other, simpler procedures to warrant the use of this more complicated technique? In hips with small, early lesions, the results obtained with fibular grafting as well as with other less technically complex procedures have generally been good. In hips with large lesions, treated after collapse, results with this procedure as well as other procedures have been much less satisfactory^1,3-5. In this latter group, the consistently excellent results obtained with primary total hip replacement, along with recent improvements in durability, make this the procedure of choice for many surgeons, even for the management of younger patients with osteonecrosis. Should free vascularized fibular grafting therefore be reserved primarily for young patients with large precollapse lesions? These questions have yet to be answered and will await the findings of additional prospective, controlled studies comparing vascularized fibular grafting to other joint-preserving procedures.

*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. 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 Relat Res. 2001;386:120-30.
2. Marciniak D, Furey C, Shaffer JW. Osteonecrosis of the femoral head. A study of 101 hips treated with vascularized fibular grafting. J Bone Joint Surg Am. 2005;87:742-7.
3. 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 ed. Philadelphia: Lippincott Williams and Wilkins. 2001. p 3263-308.
4. 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.
5. Plakseychuk AY, Kim SY, Park BC, Varitimidis SE, Rubash HE, Sotereanos DG. Vascularized compared with nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003;85:589-96.
6. Malizos KN, Seaber AV, Glisson RR, Quarles LD, Rizk WS, Urbaniak JR. The potential of vascularized cortical graft in revitalizing necrotic cancellous bone in canines. In: Urbaniak JR, Jones JP Jr, editors. Osteonecrosis: etiology, diagnosis, and treatment. 1^st ed. Rosemont, Illinois: American Academy of Orthopaedic Surgeons; 1997. p 361-71.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.