Free Fibula Graft to the Hip Fori Avascular Necrosis ARTICLE by GAIL S

Free Fibula Graft to the Hip fori Avascular Necrosis ARTICLE BY GAIL S. BOYD, CST/CFA

ree fibula grafting additional equipment, medications continued his alcohol intake postop- to the hip is contem- used in the procedure, instrumenta- eratively, which was the probable plated as treatment tion, sutures, etc. I gave inservices contributing cause for his disease). for avascular necro- to all OR personnel and hospital We have also had one major postop- sis (AVN) of the staff nurses who would be assisting erative complication. Our patient femoral head. AVN in the patients' postoperative care in was on his crutches 2 weeks postop- is a condition in which blood flow the hospital. eratively when he got one of his to the bone is restricted, causing During Dr Urbaniak's first 5 years crutches tangled up in something, that portion of the bone to die. doing free fibula grafts on 50 causing him to fall. He fractured his Pain and decreased range of patients, he reported having three femur just distal to the graft inser- motion (ROM) may result. patients whose disease progressed tion site. We reduced the fracture Although there are several meth- enough to warrant total hip arthro- and placed a cobra-type plate and ods of treatment for AVN, none is plasty, and three more patients with screws for fixation to try to preserve completely satisfactory or progressive or further collapse of the the graft. Time and future x-ray constantly successful. The purpose femoral head. films will reveal the success or fail- of this surgery is to decompress the Since we began free fibula grafts ure. femoral head, aid in structural sta- in October 1991, we have performed Close monitoring of all free fibula bility, and place healthy, vascular- 14 grafts. Of these, we have revised graft patients will ultimately deter- ized bone in the area of femoral one to a total hip (Note: the patient mine the success ratio of this proce- head necrosis, thus preserving the femoral head rather than replacing it with an artificial joint. This article will provide surgical Superficial epigastric arter technologists with a better under- standing of the disease process of AVN as well as the free fibula vas- Internal illac artery cularized grafting procedure per- formed as a method of treatment. ial external pudendal Discussion Bone grafts revascularized by microvascular anastomosis were done as experimental studies in the early to mid 1970s. Our facility, The Center for Hip and Knee Surgery, has been per- forming this procedure since October 1991. We flew to Duke Unnamed muscular branch University to observe James Urbaniak, MD, who started Descending genicular artery performing this procedure in 1979. Articular branch As Dr Keating's first assistant, I not only accompanied him to Duke University, but I also acquired the necessary information for our hos- Figure 1. Hip vessels (anterior view). (Reprinted with permission from The pital to begin performing this pro- Center for Hip & Knee Surgery, Mooresville, Indiana and adapted from: Grant cedure. The information included JCB. Grant's Atlas of Anatomy. 5th ed.)

THE SURGICAL TECHNOLOGIST weight transmitted from the thigh to the foot. The fibula provides muscle attachment and participates in the formation of the ankle. Blood is supplied to the fibula through the peroneal artery (Figure 2). The fibula graft is procured with the per- oneal artery and veins.

Patient Selection Patient selection for this procedure is influenced by several factors: 1. Age. Patients under 50 years of age may be considered for this procedure, whereas the treatment of choice in patients over 50 may be a Figure 3. Magnetic resonance imag-- Figure 2. Fibular vessels (posterior total hip arthroplasty. ing (MRI). - view). (Reprinted with permission 2. Progression of the Disease. from The Center for Hip & Knee Determining how far the disease has didates for the free fibular grafting Surgery, Mooresville, Indiana and progressed is important in deciding procedure. Of the patients adapted from: Grant JCB. Grant's the best treatment for a patient. The diagnosed with AVN of the femoral Atlas of Anatomy. 5th ed.) progression of femoral head head, 20% to 25% have no history or involvement is classified in stages known contributing causes. dure. Theoretically, it seems to be using the Steinberg criteria for stag- Patients with steroid use as the the best treatment currently avail- ing avascular necrosis (Table 1). contributing cause of their disease able and is offered to select patients Stages 11,111, and possibly early may have had an idiosyncratic reac- with AVN of the femoral head. stage IV may benefit from this pro- tion to one dose of steroids, as small cedure. as one pill from a methylpred- Anatomy and Blood Supply 3. Patient Symptoms. Patients nisolone dose pak, often given for The hip joint is formed between the should have pain and decreased treatment of poison ivy, or one injec- head of the femur and the acetabu- ROM. Asymptomatic patients as of tion of cortisone for a knee or shoul- lum. The large head of the femur now are not generally offered this der problem. High-volume steroids fits snugly into the deep acetabular procedure. used in cancer treatment may also socket of the coxa. Both the proxi- 4. Contributing Causes. Causes cause AVN. mal and distal asvects of the femur of this disease include alcoholism, In athletes diagnosed with AVN, steroid use. vrevious trauma to the the contributing cause of the disease are large, with thiproximal head .I offset from the shaft and joined to it area, or a systemic disease that is as likely to be previous trauma to by the neck. involves the vascular system (eg the area as it is to be steroid use. Blood is supplied to the femur sickle cell disease, collagen vascular through a branch of the obturator disease, or Gauchers' disease). Patient Evaluation and Preparation artery (Figure 1) that enters the Patients with such systemic diseases Magnetic resonance imaging (MRI) femoral head through the ligament would not be considered good can- is done to define the extent of the of the head of the femur and supplies a variable, but generally Table 1. Criteria for Staging; Avascular Necrosis* small, portion of the bone adjacent to the fovea. Stage Criteria The head and neck of the femur are supplied predominantly by 0 Normal or nondiagnostic x-ray film, bone scan, and MRI branches of the medial and lateral I Normal x-ray film, abnormal bone scan, and/or MRI femoral circumflex arteries (see 11 Abnormal x-ray film (cystic and sclerotic changes in the femoral head Figure 1). These branches pass prox- without collapse) imally along the neck of the femur, I11 Subchondral collapse (crescent sign) without flattening of articular where they are tethered to the bone surface by the synovial portion of the joint IV Flattening of femoral head without joint narrowing or acetabular capsule. During the grafting involvement process, the lateral or possibly the V Joint narrowing and/or acetabular involvement medial femoral circumflex arteries VI Advanced degenerative changes and veins are used for anastomosis. Although the bones of the lower *Reprinted with permission from Steinberg ME, Steinberg DR. Evaluation and leg include both the tibia and the staging of avascular necrosis. Seminars in Arthroplasty. Philadelphia, Pa: WB fibula, the tibia bears nearly all of the Saunders Co; 1991; 2(No.3).

THE SURGICAL TECHNOLOGIST MARCH 1993 this region (Figures 4 and 5). eral decubitus position (Figure 7). Autologous blood donation is Two grounding pads are placed and discussed with the patient. the patient is prepped from waistline Approximately 80% of our surgery to toes circumferentially. The patients donate their own blood if patient is then draped, with the leg postoperative transfusions are draped free and the foot and ankle expected. Blood loss for this proce- wrapped. Steri-drapes are applied dure is approximately the same as to both incision sites. A sterile for a patient undergoing a total hip tourniquet is placed just above the replacement. Normally, the patient knee. A sterile Esmarch bandage is donates 2 units of blood. used to exsanguinate the leg, and the Patients who smoke must be tourniauet is inflated. The C-arm is advised to stop smoking during the drapedsterile (both ends) and first 3 weeks after the graft. brought in from the anterior side of If alcohol is a contributing cause the patient (see Figure 7). UV lights Figure 4. Hip angiogram. of disease in a patient, it must also are turned on as soon as the patient be determined if this patient will is draped. involvement and changes in the continue to abuse alcohol. If so, the femoral head, not only for the hip patient would be at higher risk for Operative Procedure displaying symptoms, but for the an unsuccessful outcome since the The entire procedure takes approxi- other hip as well, since there is at revascularized hip would probably mately 6 hours. Two surgical teams least a 50% chance that the other suffer the same effects and would operate simultaneously during much asymptomatic hip is already fail, requiring additional surgery of the case; one team will harvest the involved or will become involved in (total hip replacement). fibula graft along with the vascular the disease process within the next pedicle, while the other team pre- few months. Involvement of the Preoperative Preparation pares the hip to receive the graft. knees or shoulders has also been Operating room personnel prepare The most important attribute for recorded in 10% to 15% of the preoperatively by ensuring the nec- an assistant or a scrub person during patients with AVN. essary special equipment and drugs this procedure is the ability to work MRI will reveal changes in the are available. Some of the special as a team member. Confusion may femoral head earlier than regular x- items required may include the fol- result when two to four surgeons ray films (Figure 3), which will allow lowing, depending on the surgeon's operate on one patient at the same for proper staging of the disease. preference: time. Being flexible and quick to Angiograms are also done on the C-arm radiographic imager and respond to stated or unstated needs operative lower extremity because draping for both arms at either incision site can make a the vascular anatomy is variable in Custom-made reamers and ball long and potentially difficult case a reamers (Figure 6) smooth experience for all involved. Sterile tourniquet Microscope Preparing the Hip Headlight A Watson Tones incision is made Power equipment (saws, drills, over the hip. A tract or bed is made reamers) with careful dissection to provide Vascular setup protection to the vessels to be anas- Major ortho setup tomosed. This tract will usually uti- Two electrosurgical machines lize the interval between the tensor Bipolar unit fasciae latae muscle and the rectus Two suction units femoris (Figure 8). With careful dis- UV lighting: All protective section, the lateral femoral circum- gear required (long-sleeved flex artery and vein are identified jackets, eyewear, sunscreen, and exposed to later serve as the gloves, etc). Lighting is deter- anastomosis site. The lateral cortex mined by the facility or surgeon's preference. Heparinized saline Radiopaque dye/saline (50/50 mixture) Papaverine Absorbable gelatin sponge and thrombin 0.25% bupivacaine HCI with epinephrine Figure 5. Lower leg angiogram. The patient is placed in the lat- Figure 6. Reamers and ball tips. is used to check the reamed tract for the graft. After irrigating and suc- tioning for dye removal, cancellous bone chips, which have been saved throughout the case, are packed into the area of previouslv excised necrotic bone. hehip is'now ready to receive the graft.

Procuring the Fibula Graft As the hip team works, the vascular Figure 7. Lateral decubitus position team prepares the graft. A longitu- Figure 9. Fibular graft. and fleurs. dinal lateral incision is made over the midportion of the fibula. The vessels are dissected free, the tourni- peroneal nerve is identified and quet is deflated and the fibula graft of the femur is then perforated with carefully retracted to prevent any a drill bit just distal to the greater site may be closed. During closure, damage to the nerve. The peroneal 0.25% bupivacaine with epinephrine trochanter. A guide wire is then artery and vein are identified, as passed into the femoral neck and is injected subcutaneously. A drain well as the posterior tibia1 artery. head under fluoroscopic imaging, is utilized. Approximately a 12- to 15-cm (5- to taking care not to penetrate the 6-inch) midthird section of the articular cartilage. With the guide Graft Placement and Anastomosis fibula is carefully dissected free. The fibula with its vascular pedicle pin in proper location, the special Two osteotomies are made, again cannulated reamers (see Figure 6) is trimmed to appropriate length. A identifying the peroneal artery and notch may be taken from the cortex are reamed over the pin, creating a vein. The fibula is elevated from core approximately 3/4 inch in of the femur with a rongeur and soft tissue, leaving little to no tissue smoothed at the graft insertion site diameter (depending on the attached to the fibula except around patient's size). The reamers are 16 if needed to prevent any compres- the vascular pedicle. The peroneal sion of the vascular pedicle. With mm, 19 mm, 21 mm, or 23 mm in artery and vein are preserved with size. The ball-tipped reamers (see the use of fluoroscopic imaging, the the graft, maintaining as long a vas- graft is inserted and a .062 K-wire is Figure 6) are then used to remove or cular pedicle of artery and vein as burr out the necrosed area in the placed through the graft and proxi- can possibly be harvested (usually 4 mal femur to prevent migration of femoral head. Radiopaque dye to 6 mm) (Figure 9). Patency of the mixed equally with injectable saline the graft, as can be seen in postoper- graft is checked. After the graft and ative films (Figure 10). The microscope is then brought into the field. The UV lights are .- turned off to protect the surgeons' bl. ' /--Inguinal ligament eyes who are using the microscope. An end-to-end anastomosis is per- formed between the peroneal ves- Tensor fasciae latae femoral sels and branches of the femoral cir- cumflex vessels using the operating Itaneous) microscope and usually 9-0 nylon suture. After anastomosis is com- plete, the peroneal artery should Tract utilized tor pulsate and the fibula graft should Pectineus bleed, indicating a successful and Lateral circumflex femoral arte patent anastomosis. '' k~dductorlongus Pmfunda femoris artery and vei The hip wound is then ready for ~Gracilis closure. A drain is optional. During f-- emo oral artery and vein closure, 0.25% bupivacaine HCI Nerve to vastus medialis -Saphenous nerve with epinephrine is injected sub- I cutaneously. Rectus femoris- 1 -Sartorius Complications As in any surgical procedure, the possibility of complications exists. Possible complications for this pro- Figure 8. Muscularature of the hip. (Reprinted with permission from The Center cedure include the following: for Hip & Knee Surgery, Mooresville, Indiana and adapted from: Grant JCB. 1. Penetration of the femoral Grant's Atlas of Anatomy. 5th ed.) head or neck during reaming.

THE SURGICAL T patient's entire extremity is wrapped with elastic bandages and a knee immobilizer, and a space boot (a type of short leg splint) (Figure 11)is applied.

Postoperative Care Low molecular weight dextran, 40 mg is given, 500 cc in 8 hours, for 5 days postoperatively to help pre- vent deep vein thrombosis. The patient is hospitalized for approxi- mately 7 days and is seen 3 weeks Figure 10. Postoperative x-ray film postoperatively (2 weeks after hos- showing k-wire. pital discharge) in the office. The patient is seen again at 3 months, 6 Penetration should be avoided months, 1 year, and every 2 years because of the use of fluoroscopic thereafter for x-ray films and exam- imaging during the reaming. ination. The patient is foot-flat 2. Infection. Postoperative infec- weightbearing on the affected hip tion may be treated with antibiotics; for at least 3 months Figure 12. Location of fibular however, good sterile technique, the postoperatively and then full removal and graft to the hip. use of prophylactic antibiotics, and weightbearing is attained gradu- (Reproduced from Urbaniak JR, the use of UV lights should elimi- ally. MD. Free Vascularized Fibular Graft nate most infection. for Avascular Necrosis of the Hip. 3. Femoral fractures at distal graft Summary Durham, NC: Duke University insertion site. Fractures should only A free fibula graft consists of Medical Center.) occur as a result of a trauma (ie, a removing dead bone with a lack of fall or a physical blow) to insertion blood supply from the hip and DS, eds. Bone Circulation. Baltimore, site, due to changed structural replacing it with healthy vascular- Md: Williams and Wilkins Co; 1984. integrity of the bones following sur- ized bone from the lower leg Steinberg ME, Steinberg DR. Evaluation gical procedure. (Figure 12). It is hoped that this and staging of avascular necrosis. procedure will prevent the necrosis Seminars in Arthroplasty. Philadelphia, 4. Deep vein thrombosis. This is Pa: WB Saunders Co; 1991;2(No. 3). due to length of procedure and of the femoral head from progress- Taylor GI, Miller GDH, Ham FJ. The free manipulation of vascular structures ing to the point of collapse and will vascularized bone graft. A clinical in the leg. restore vascularization and new extension of microsurgical techniques. 5. Wound breakdown. Wound bone formation. A Plast Reconstr Surg. 1975;55:533. breakdown could be caused by dis- Urbaniak JR, ed. Aseptic necrosis of the Acknowledgments femoral head treated by vascularized ruption of blood supply after resec- fibula graft. ~icrosur~kryfor Major Limb tion of peroneal artery and vein. The author would like to thank E. Reconstruction. St Louis, Mo: Mosby; 6. Peroneal nerve injury. Injury Michael Keating, MD, for his assis- 1987. occurs when nerve is stretched, tance with this article, and Linda Urbaniak JR. Avascular necrosis of the roughened, or lacerated during Clem, Mary Ann McDaniel, and femoral head treated by vascularized surgery. Nerve damage should be Carol Hubbard for their help with fibula graft. Orthopaedic Transactions. typing and illustrations. J Bone joint Surg Am; 1985. avoided by careful protection Yoo MC, Chung DW, Hahn CS. Free vas- throughout the case. cularized fibula grafting for the treat- Bibliography ment of osteonecrosis of the femoral Dressings Grant JCB. Grant's Atlas of Anatomy. 5th head. Clin Orthop. Philadelphia, Pa: JB ed. Baltimore, Md: Williams and Lippincott Co; 1992; 277. A regular hip dressing is used. The Wilkins Co; 1962. Ostrup LT, Fredrickson TM. Distant trans- fer of a free, living bone graft by Gail S. Boud. microvascular anastomosis: An experi- CSTICFA,ia; been a mental study. Plast Reconstr Surg. CST since 1985 and 1974;52:274-285. worked in a hospital Richards RR. Bone grafting with operating room for 5 microvascular anastomosis in years. For the last 2- ID years she has been osteonecrosis of the femoral head. employed as a private Seminars in Arthroplasty. Philadelphia, assistant for E. Pa: WB Saunders Co; 1991;2(No. 3). Michael Keating, MD, Steinberg ME, Haykem GD, Steinberg DR. an orthopedic surgeon A new method for evaluating and stag- at The Centerfor Hip ing of avascular necrosis of the femoral 6 Knee Surgery in Figure 11. Postoperative dressings. head. In: Arlet J, Picat P, Hungerford Mooresville, Indiana.

THE SURGICAL TECHNOLOGIST