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Osteonecrosis of the Femoral Head. Surgical Technique Free This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you requested follows this cover page. Free Vascularized Fibular Grafting for the Treatment of Postcollapse Osteonecrosis of the Femoral Head. Surgical Technique J. Mack Aldridge, III, Keith R. Berend, Eunice E. Gunneson and James R. Urbaniak J Bone Joint Surg Am. 2004;86:87-101. This information is current as of August 9, 2009 Reprints and Permissions Click here to order reprints or request permission to use material from this article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org COPYRIGHT © 2004 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Free Vascularized Fibular Grafting for the Treatment of Postcollapse Osteonecrosis of the Femoral Head Surgical Technique By J. Mack Aldridge III, MD, Keith R. Berend, MD, Eunice E. Gunneson, PA-C, and James R. Urbaniak, MD Investigation performed at Duke University Medical Center, Durham, North Carolina The original scientific article in which the surgical technique was presented was published in JBJS Vol. 85-A, pp. 987-993, June 2003 SURGICAL TECHNIQUE ABSTRACT Overview In its early stages, free vascularized fibular grafting of the femoral BACKGROUND: head required two teams of surgeons and an operative time of six Osteonecrosis of the femoral hours or more. Today, thanks in large part to the development of tech- head, a disease primarily affect- nical shortcuts, customized instrumentation, and an operative sup- ing young adults, is often associ- port staff familiar with the nuances of the surgery, free vascularized ated with collapse of the articular fibular grafting of the femoral head can easily be performed in be- surface and subsequent arthro- tween two and one-half and three hours, with two surgeons and one sis. Free vascularized fibular scrub nurse. grafting has been reported to be successful for patients with early The procedure is performed with the patient under general anes- stages of osteonecrosis, but little thesia, with the adjunct of an epidural block, which remains in place is known about its efficacy after for twenty-four to forty-eight hours postoperatively. The patient is the femoral head has collapsed. placed in the lateral decubitus position and is supported by a peg- board. Pegs are placed at the level of the sacral ala posteriorly and the METHODS: pubic symphysis anteriorly. Careful attention is paid to padding all os- We retrospectively reviewed the results in a consecutive series of seous prominences, and the placement of an axillary pad is standard. 188 patients (224 hips) who had The entire lower extremity to the level of the iliac crest proximally is undergone free vascularized fibu- prepared and draped. The lower limb is covered with an impervious lar grafting, between 1989 and stocking up to the midpart of the thigh, and a sterile tourniquet is 1999, for the treatment of os- placed over the stocking (just proximal to the knee), to be used during teonecrosis of the hip that had the fibular graft harvest. A Betadine-impregnated occlusive drape is led to collapse of the femoral- used for both the hip and leg. The operative procedure on the hip and head but not to arthrosis. The the harvest of the fibular graft are performed at the same time, and, as continued such, cooperation between the surgeons is required. THE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2004 · VOLUME 86-A · SUPPLEMENT NUMBER 1 · JBJS.ORG anterior elevation of the lateral ABSTRACT | continued musculature. The peroneals are then sharply reflected off the lat- average duration of follow-up was associated with alcohol abuse, or eral aspect of the fibula, with the 4.3 years (range, two to twelve posttraumatic fared worse than did years). We defined conversion to to- those with other causes, including surgeon working from posterior tal hip arthroplasty as the failure steroid use. Survival of the joint to anterior and stopping when end point, and we analyzed the con- was not significantly related to the the anterior intermuscular sep- tribution, to failure, of the size of size of the femoral head lesion, but tum is completely visualized the lesion, amount of preoperative there was an increased relative risk along the anticipated 15-cm seg- collapse of the femoral head, etiol- of conversion to total hip arthro- ment of fibula to be removed. ogy of the osteonecrosis, age of plasty with increasing lesion size Because preservation of the the patient, and bilaterality of the and amount of collapse. Neither pa- periosteum is paramount to the lesion. We used the Harris hip tient age nor bilaterality significantly score to evaluate clinical status affected outcome. success of the vascularized graft, preoperatively and at the time of we recommend retaining a thin the most recent follow-up. CONCLUSIONS: (1 to 2-mm) layer of muscle. Patients with postcollapse, prede- This “marbleizing” technique re- RESULTS: generative osteonecrosis of the sults in a cobblestone appear- The overall rate of survival was femoral head appear to benefit ance to the fibular periosteum 67.4% for the hips followed for a from free vascularized fibular graft- (Fig. 2). minimum of two years and 64.5% ing, with good overall survival of for those followed for a minimum of the joint and significant improve- The anterior intermuscular five years. The mean preoperative ment in the Harris hip score. The septum is then divided, exposing Harris hip score was 54.5 points, results of this femoral head- the anterior musculature, which and it increased to 81 points for the preserving procedure in patients is reflected off the fibula with the patients in whom the surgery suc- with postcollapse osteonecrosis use of a right-angle clamp and ceeded; 63% of the patients in that are superior to those of core de- Metzenbaum scissors. Small vas- group had a good or excellent re- compression and nonoperative cular perforators are controlled sult. There was a significant rela- treatment, as reported in the with bipolar electrocautery and tionship between the outcome of literature. Patients with larger le- the grafting procedure and the etiol- sions and certain diagnoses, such vascular clips. At this point, the ogy of the osteonecrosis (p = as idiopathic and alcohol-related interosseous membrane is easily 0.017). Patients in whom the osteonecrosis, have worse visualized and the adjacent ante- osteonecrosis was idiopathic, outcomes. rior musculature and accompa- nying deep peroneal nerve and anterior tibial artery are gently Fibular Graft Harvest (Fig. 1). With maintenance of swept off the interosseous mem- The lower extremity is exsan- full-thickness flaps, the fascia of brane away from the fibula. With guinated with an Esmarch ban- the lateral compartment is the use of a specially designed dage, and the tourniquet is readily visualized and is incised right-angle Beaver blade, the in- inflated to 350 mm Hg. A in line with the skin incision. In terosseous membrane is divided straight lateral 15-cm longitudi- an anterior direction, the pero- close to its fibular attachment nal incision is made coincident neal muscles are reflected bluntly along the entire length of the with the natural sulcus between off the posterior intermuscular proposed fibular graft (Fig. 3). the lateral and posterior com- septum up to the level of the fib- Palpation between the tibia and partments of the leg. The inci- ula, which is readily palpated. fibula reveals whether the release sion is begun 10 cm distal to the Two Gelpi self-retaining retrac- of the interosseous membrane fibular head and ends 10 cm tors are then placed at both ex- has been completed. The poste- proximal to the lateral malleolus tents of the wound to assist in rior intermuscular septum is THE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2004 · VOLUME 86-A · SUPPLEMENT NUMBER 1 · JBJS.ORG (Fig. 4). Simultaneously, irriga- tion is used to prevent thermal osteonecrosis. The proximal pedicle is next identified deep to the soleus muscle along the pos- terior aspect of the fibula. It is protected, and the proximal fibu- lar osteotomy is performed in a manner similar to the distal os- teotomy. The fibular cuts are made 15 cm apart, to ensure an adequate pedicle length. When performing the proximal osteot- omy, it is important to identify FIG. 1 and protect the superficial pero- A 15-cm incision is made on the lateral aspect of the leg between the lateral and poste- neal nerve, which is exposed rior compartments. The incision is begun 10 cm distal to the fibular head (PF) and ends proximally on the deep surface of 10 cm proximal to the tip of the lateral malleolus (LM). the peroneus longus muscle. Once the fibula has been cut then divided, exposing the poste- After the surgeon rechecks to en- both proximally and distally, a rior muscles (the soleus proxi- sure that the planned osteotomy bone clamp is placed around it to mally and the flexor hallucis is at least 10 cm proximal to the allow better control and easier longus distally). lateral malleolus, an oscillating rotation during the delicate pedi- saw is used to cut the fibula cle dissection. Starting distally, Fibular Osteotomy Directly beneath the distal as- pect of the flexor hallucis longus muscle, the distal pedicle of the peroneal vessels is identified and, under direct vision, a right-angle clamp is passed along the poste- rior aspect of the fibula, just anterior to and away from the vascular pedicle. With the clamp interposed between the fibula and the vessels, a malleable re- tractor is passed between the clamp and bone.
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