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J Reconstr Microsurg 2017; 33(03): 163-172
DOI: 10.1055/s-0036-1594294
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Effectiveness of Free Vascularized Fibular Flaps in Osteonecrosis of the Femoral Head and Neck: A Systematic Review

Cassandra A. Ligh
1   Division of Plastic Surgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Jonas A. Nelson
1   Division of Plastic Surgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
John P. Fischer
1   Division of Plastic Surgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
Stephen J. Kovach
1   Division of Plastic Surgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
,
L. Scott Levin
1   Division of Plastic Surgery, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
› Author Affiliations
Further Information

Publication History

19 August 2016

08 October 2016

Publication Date:
16 January 2017 (online)

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Abstract

Background Free vascularized fibular flaps (FVFFs) are accepted surgical options to treat osteonecrosis of the femoral head and neck (ONFHN) to prevent conversion to total hip replacement (THR), yet many studies are single institution cohorts, with little generalizability.

Purpose The purpose of this study was to perform a systematic review examining the comparative effectiveness of FVFF to treat ONFHN, particularly preventing conversion to a THR and improving hip function/symptoms.

Methods We searched PubMed and EMBASE databases using femoral head, free fibula, and femoral neck keywords. Articles were excluded if not translated into English, n < 10 hips, article was a compilation/review, outcomes were not relevant, or prior to 1994. If from the same institution, we included the largest cohort and excluded others within the same timeline. Two investigators independently reviewed articles and reported number of patients/hips, average age/follow-up time/graft survival before THR, Harris hip score, THR rate, complications, and radiographic progression rates.

Results We identified 128 and 157 articles from PubMed and EMBASE. After screening/duplicate removal, 21 studies were included from 14 institutions in 9 countries. Overall, 71% were level IV evidence. The average patient number was 129, number of hips was 166, age at surgery was 34 years, and follow-up time was 92 months. HHS improved on average 21.7 points, with the number of patients requiring THR being 19.4%. Graft survival before THR was 5.2 years, and 47.7% of hips had radiographic progression.

Conclusions There is a significant amount of level IV evidence describing the favorable role of FVFF to treat ONFHN. Although efficacious, there is a need for higher level evidence. The level of evidence is 3.

Keywords

osteonecrosis of the femoral head and neck - systematic review - free vascularized fibular flap

Note

Cassandra Ligh and Jonas A. Nelson contributed equally to this work.


 

  • References

  • 1 Aldridge III JM, Urbaniak JR. Vascularized fibular grafting for osteonecrosis of the femoral head with unusual indications. Clin Orthop Relat Res 2008; 466 (5) 1117-1124
    CrossrefPubMedGoogle Scholar
  • 2 Aldridge III JM, Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. Surgical technique. J Bone Joint Surg Am 2004; 86-A (Suppl. 01) 87-101
    PubMedGoogle Scholar
  • 3 Aldridge III JM, Urbaniak JR. Free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. Tech Orthop 2008; 23: 44-53
    CrossrefPubMedGoogle Scholar
  • 4 Bertrand T, Urbaniak JR, Lark RK. Vascularized fibular grafts for avascular necrosis after slipped capital femoral epiphysis: is hip preservation possible?. Clin Orthop Relat Res 2013; 471 (7) 2206-2211
    CrossrefPubMedGoogle Scholar
  • 5 Chen SB, Gao YS, Zhu ZH, Jin DX, Cheng XG, Zhang CQ. Pain relief following osteonecrosis of the femoral head treated by free vascularized fibular grafting. Eur J Orthop Surg Traumatol 2012; 22 (8) 689-693
    CrossrefPubMedGoogle Scholar
  • 6 Cho BC, Kim SY, Lee JH, Ramasastry SS, Weinzweig N, Baik BS. Treatment of osteonecrosis of the femoral head with free vascularized fibular transfer. Ann Plast Surg 1998; 40 (6) 586-593
    CrossrefPubMedGoogle Scholar
  • 7 Dailiana ZH, Gunneson EE, Urbaniak JR. Heterotopic ossification after treatment of femoral head osteonecrosis with free vascularized fibular graft. J Arthroplasty 2003; 18 (1) 83-88
    CrossrefPubMedGoogle Scholar
  • 8 Dailiana ZH, Toth AP, Gunneson E, Berend KR, Urbaniak JR. Free vascularized fibular grafting following failed core decompression for femoral head osteonecrosis. J Arthroplasty 2007; 22 (5) 679-688
    CrossrefPubMedGoogle Scholar
  • 9 Davis ET, McKee MD, Waddell JP, Hupel T, Schemitsch EH. Total hip arthroplasty following failure of free vascularized fibular graft. J Bone Joint Surg Am 2006; 88 (Suppl. 03) 110-115
    PubMedGoogle Scholar
  • 10 Dean GS, Kime RC, Fitch RD, Gunneson E, Urbaniak JR. Treatment of osteonecrosis in the hip of pediatric patients by free vascularized fibular graft. Clin Orthop Relat Res 2001; (386) 106-113
    PubMedGoogle Scholar
  • 11 Ding H, Chen SB, Lin S, Gao YS, Zhang CQ. The effect of postoperative corticosteroid administration on free vascularized fibular grafting for treating osteonecrosis of the femoral head. Sci World J 2013; 2013: 708014
    PubMedGoogle Scholar
  • 12 Ding H, Gao YS, Chen SB, Jin DX, Zhang CQ. Free vascularized fibular grafting benefits severely collapsed femoral head in concomitant with osteoarthritis in very young adults: a prospective study. J Reconstr Microsurg 2013; 29 (6) 387-392
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Eward WC, Rineer CA, Urbaniak JR, Richard MJ, Ruch DS. The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible?. Clin Orthop Relat Res 2012; 470 (10) 2819-2826
    CrossrefPubMedGoogle Scholar
  • 14 Feng Y, Wang S, Jin D , et al. Free vascularised fibular grafting with OsteoSet®2 demineralised bone matrix versus autograft for large osteonecrotic lesions of the femoral head. Int Orthop 2011; 35 (4) 475-481
    CrossrefPubMedGoogle Scholar
  • 15 Gao YS, Chen SB, Jin DX, Sheng JG, Cheng XG, Zhang CQ. Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: results from a series of 407 cases. Microsurgery 2013; 33 (8) 646-651
    CrossrefPubMedGoogle Scholar
  • 16 Gao YS, Liu XL, Sheng JG, Zhang CQ, Jin DX, Mei GH. Unilateral free vascularized fibula shared for the treatment of bilateral osteonecrosis of the femoral head. J Arthroplasty 2013; 28 (3) 531-536
    CrossrefPubMedGoogle Scholar
  • 17 Garberina MJ, Berend KR, Gunneson EE, Urbaniak JR. Results of free vascularized fibular grafting for femoral head osteonecrosis in patients with systemic lupus erythematosus. Orthop Clin North Am 2004; 35 (3) 353-357 , x
    CrossrefPubMedGoogle Scholar
  • 18 Garrigues GE, Aldridge III JM, Friend JK, Urbaniak JR. Free Vascularized Fibular Grafting for treatment of osteonecrosis of the femoral head secondary to hip dislocation. Microsurgery 2009; 29 (5) 342-345
    CrossrefPubMedGoogle Scholar
  • 19 Gaskill TR, Urbaniak JR, Aldridge III JM. Free vascularized fibular transfer for femoral head osteonecrosis: donor and graft site morbidity. J Bone Joint Surg Am 2009; 91 (8) 1861-1867
    CrossrefPubMedGoogle Scholar
  • 20 Judet H, Gilbert A. Long-term results of free vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res 2001; (386) 114-119
    PubMedGoogle Scholar
  • 21 Judet H, Judet J, Gilbert A. Vascular microsurgery in orthopaedics. Int Orthop 1981; 5 (2) 61-68
    CrossrefPubMedGoogle Scholar
  • 22 Jun X, Chang-Qing Z, Kai-Gang Z, Hong-Shuai L, Jia-Gen S. Modified free vascularized fibular grafting for the treatment of femoral neck nonunion. J Orthop Trauma 2010; 24 (4) 230-235
    CrossrefPubMedGoogle Scholar
  • 23 Kawate K, Yajima H, Sugimoto K , et al. Indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. BMC Musculoskelet Disord 2007; 8: 78
    CrossrefPubMedGoogle Scholar
  • 24 Kim SY, Kim YG, Kim PT, Ihn JC, Cho BC, Koo KH. Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head. J Bone Joint Surg Am 2005; 87 (9) 2012-2018
    CrossrefPubMedGoogle Scholar
  • 25 LeCroy CM, Rizzo M, Gunneson EE, Urbaniak JR. Free vascularized fibular bone grafting in the management of femoral neck nonunion in patients younger than fifty years. J Orthop Trauma 2002; 16 (7) 464-472
    CrossrefPubMedGoogle Scholar
  • 26 Liang K, Xiang Z, Chen S , et al. Folded free vascularized fibular grafts for the treatment of subtrochanteric fractures complicated with segmental bone defects. J Trauma Acute Care Surg 2012; 72 (5) 1404-1410
    CrossrefPubMedGoogle Scholar
  • 27 Louie BE, McKee MD, Richards RR , et al. Treatment of osteonecrosis of the femoral head by free vascularized fibular grafting: an analysis of surgical outcome and patient health status. Can J Surg 1999; 42 (4) 274-283
    PubMedGoogle Scholar
  • 28 Montella BJ, Nunley JA, Urbaniak JR. Osteonecrosis of the femoral head associated with pregnancy. A preliminary report. J Bone Joint Surg Am 1999; 81 (6) 790-798
    PubMedGoogle Scholar
  • 29 Nagi ON, Dhillon MS, Goni VG. Open reduction, internal fixation and fibular autografting for neglected fracture of the femoral neck. J Bone Joint Surg Br 1998; 80 (5) 798-804
    CrossrefPubMedGoogle Scholar
  • 30 Nagi ON, Gautam VK, Marya SK. Treatment of femoral neck fractures with a cancellous screw and fibular graft. J Bone Joint Surg Br 1986; 68 (3) 387-391
    PubMedGoogle Scholar
  • 31 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-A (4) 589-596
    PubMedGoogle Scholar
  • 32 Roush TF, Olson SA, Pietrobon R, Braga L, Urbaniak JR. Influence of acetabular coverage on hip survival after free vascularized fibular grafting for femoral head osteonecrosis. J Bone Joint Surg Am 2006; 88 (10) 2152-2158
    PubMedGoogle Scholar
  • 33 Sabesan VJ, Pedrotty DM, Urbaniak JR, Ghareeb GM, Aldridge JM. Free vascularized fibular grafting preserves athletic activity level in patients with osteonecrosis. J Surg Orthop Adv 2012; 21 (4) 242-245
    CrossrefPubMedGoogle Scholar
  • 34 Sotereanos DG, Plakseychuk AY, Rubash HE. Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head. Clin Orthop Relat Res 1997; (344) 243-256
    PubMedGoogle Scholar
  • 35 Sun Y, Zhang C, Jin D, Sheng J, Cheng X, Zeng B. Treatment for large skeletal defects by free vascularized fibular graft combined with locking plate. Arch Orthop Trauma Surg 2010; 130 (4) 473-479
    CrossrefPubMedGoogle Scholar
  • 36 Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am 1995; 77 (5) 681-694
    CrossrefPubMedGoogle Scholar
  • 37 Xie X, Zhang C, Jin D, Chen S, Gao Y. Free vascularised fibular graft for neglected femoral neck fractures in young adults. Hip Int 2012; 22 (3) 319-323
    CrossrefPubMedGoogle Scholar
  • 38 Yen CY, Tu YK, Ma CH, Yu SW, Kao FC, Lee MS. Osteonecrosis of the femoral head: comparison of clinical results for vascularized iliac and fibula bone grafting. J Reconstr Microsurg 2006; 22 (1) 21-24
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Yin S, Zhang C, Jin D, Chen S, Sun Y, Sheng J. Treatment of osteonecrosis of the femoral head in lymphoma patients by free vascularised fibular grafting. Int Orthop 2011; 35 (8) 1125-1130
    CrossrefPubMedGoogle Scholar
  • 40 Yoo MC, Chung DW, Hahn CS. Free vascularized fibula grafting for the treatment of osteonecrosis of the femoral head. Clin Orthop Relat Res 1992; (277) 128-138
    PubMedGoogle Scholar
  • 41 Yoo MC, Kim KI, Hahn CS, Parvizi J. Long-term followup of vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res 2008; 466 (5) 1133-1140
    CrossrefPubMedGoogle Scholar
  • 42 Zhang C, Zeng B, Xu Z , et al. Treatment of femoral head necrosis with free vascularized fibula grafting: a preliminary report. Microsurgery 2005; 25 (4) 305-309
    CrossrefPubMedGoogle Scholar
  • 43 Zhang CQ, Sun Y, Chen SB , et al. Free vascularised fibular graft for post-traumatic osteonecrosis of the femoral head in teenage patients. J Bone Joint Surg Br 2011; 93 (10) 1314-1319
    CrossrefPubMedGoogle Scholar
  • 44 Sun Y, Feng Y, Zhang C , et al. Beneficial effect of autologous transplantation of endothelial progenitor cells on steroid-induced femoral head osteonecrosis in rabbits. Cell Transplant 2011; 20 (2) 233-243
    CrossrefPubMedGoogle Scholar
  • 45 Zhang C, Zeng B, Sui S , et al. [Surgical technique of modified free vascularized fibular grafting for treatment of osteonecrosis of the femoral head]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2005; 19 (9) 692-696
    PubMedGoogle Scholar
  • 46 Zhang CQ, Gao YS, Zhu ZH, Yu XW. Why we choose free vascularized fibular grafting for osteonecrosis of the femoral head?. Microsurgery 2011; 31 (5) 417-418
    CrossrefPubMedGoogle Scholar
  • 47 He ZY, Di ZL, Tao K, Zhang JH, Feng JX, Wu HS. [Short-term result of hip resurfacing arthroplasty in the treatment of patients with femoral head necrosis]. Zhongguo Gu Shang 2011; 24 (12) 997-1000
    PubMedGoogle Scholar
  • 48 Zhao D, Zhang Y, Wang W , et al. [Comparison of total hip replacement and transplantation of vascularized bone graft in treating late ischemic necrosis of the femoral head]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2005; 19 (9) 700-702
    PubMedGoogle Scholar
  • 49 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 (4) 742-747
    CrossrefPubMedGoogle Scholar
  • 50 Tetik C, Başar H, Bezer M, Erol B, Ağir I, Esemenli T. Comparison of early results of vascularized and non-vascularized fibular grafting in the treatment of osteonecrosis of the femoral head. Acta Orthop Traumatol Turc 2011; 45 (5) 326-334
    PubMedGoogle Scholar
  • 51 Ali SA, Christy JM, Griesser MJ, Awan H, Pan X, Ellis TJ. Treatment of avascular necrosis of the femoral head utilising free vascularised fibular graft: a systematic review. Hip Int 2014; 24 (1) 5-13
    CrossrefPubMedGoogle Scholar
  • 52 Kane SM, Ward WA, Jordan LC, Guilford WB, Hanley Jr EN. Vascularized fibular grafting compared with core decompression in the treatment of femoral head osteonecrosis. Orthopedics 1996; 19 (10) 869-872
    PubMedGoogle Scholar
  • 53 Scully SP, Aaron RK, Urbaniak JR. Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am 1998; 80 (9) 1270-1275
    CrossrefPubMedGoogle Scholar
  • 54 Watters TS, Browne JA, Orlando LA, Wellman SS, Urbaniak JR, Bolognesi MP. Cost-effectiveness analysis of free vascularized fibular grafting for osteonecrosis of the femoral head. J Surg Orthop Adv 2011; 20 (3) 158-167
    PubMedGoogle Scholar
  • 55 Chen B, Xu H, Corbin DR, Ildstad ST. A clinically feasible approach to induce delayed tolerance in recipients of prior kidney or vascularized composite allotransplants. Transplantation 2012; 94 (7) 671-678
    PubMedGoogle Scholar
  • 56 He Y, Zhang ZY, Zhu HG, Wu YQ, Fu HH. Double-barrel fibula vascularized free flap with dental rehabilitation for mandibular reconstruction. J Oral Maxillofac Surg 2011; 69 (10) 2663-2669
    CrossrefPubMedGoogle Scholar
  • 57 Hu Y, Li S, Zhang Z , et al. [Combined vascularized iliac osteo-musculo-cutaneous flap with zygomatic implant anchorage in reconstructing 1 case of maxillary defect]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2005; 19 (10) 807-810
    PubMedGoogle Scholar
  • 58 Huang K, Zhang XW, Shen LF, Guo QF, Zhang C. Reconstruction of complex ankle joint defects using a composite free anterolateral thigh musculocutaneous flap with vascularized fascia lata: a 20-year follow-up. Plast Reconstr Surg 2011; 127 (3) 83e-85e
    CrossrefPubMedGoogle Scholar
  • 59 Kim WS, Kim HK. Tissue engineered vascularized bone formation using in vivo implanted osteoblast-polyglycolic acid scaffold. J Korean Med Sci 2005; 20 (3) 479-482
    CrossrefPubMedGoogle Scholar
  • 60 Kimata Y, Sakuraba M, Hishinuma S, Ebihara S, Hayashi R, Asakage T. Free vascularized nerve grafting for immediate facial nerve reconstruction. Laryngoscope 2005; 115 (2) 331-336
    Google Scholar
  • 61 Liang K, Cen S, Xiang Z, Zhong G, Yi M, Huang F. Massive juxta-articular defects of the distal femur reconstructed by series connected double-strut free-vascularized fibular grafts. J Trauma Acute Care Surg 2012; 72 (2) E71-E76
    CrossrefPubMedGoogle Scholar
  • 62 Liu X, Sheng J, Zhang C, Jin D, Mei G. [Treatment of bilateral avascular necrosis of femoral head by free vascularized fibula grafting with unilateral fibula as donor]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2011; 25 (6) 641-645
    PubMedGoogle Scholar
  • 63 Sakuraba M, Kimata Y, Iida H, Beppu Y, Chuman H, Kawai A. Pelvic ring reconstruction with the double-barreled vascularized fibular free flap. Plast Reconstr Surg 2005; 116 (5) 1340-1345
    Google Scholar
  • 64 Zhang CQ, Wang KZ, Zeng BF , et al. Free vascularized fibular grafting for treatment of old femoral neck fractures. Chin Med J (Engl) 2005; 118 (9) 786-789
    PubMedGoogle Scholar
  • 65 Haines ML, Anderson RP, Gibson PR. Systematic review: The evidence base for long-term management of coeliac disease. Aliment Pharmacol Ther 2008; 28 (9) 1042-1066
    CrossrefPubMedGoogle Scholar
  • 66 Margaliot Z, Chung KC. Systematic reviews: a primer for plastic surgery research. Plast Reconstr Surg 2007; 120 (7) 1834-1841
    CrossrefPubMedGoogle Scholar
  • 67 Ng TT, McGory ML, Ko CY, Maggard MA. Meta-analysis in surgery: methods and limitations. Arch Surg 2006; 141 (11) 1125-1130 , discussion 1131
    CrossrefPubMedGoogle Scholar
  • 68 Wright RW, Brand RA, Dunn W, Spindler KP. How to write a systematic review. Clin Orthop Relat Res 2007; 455 (455) 23-29
    CrossrefPubMedGoogle Scholar
  • 69 Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969; 51 (4) 737-755
    CrossrefPubMedGoogle Scholar
  • 70 Dong N, Yang C, Li SQ, Gao YH, Liu JG, Qi X. Effect of preoperative leg length discrepancy on functional outcome and patient satisfaction after total hip arthroplasty in cases of osteonecrosis of the femoral head. J Arthroplasty 2016; 31 (12) 2789-2794
    CrossrefPubMedGoogle Scholar
  • 71 Lee GW, Park KS, Kim DY, Lee YM, Eshnazarov KE, Yoon TR. Results of total hip arthroplasty after core decompression with tantalum rod for osteonecrosis of the femoral head. Clin Orthop Surg 2016; 8 (1) 38-44
    CrossrefPubMedGoogle Scholar
  • 72 Ollivier M, Parratte S, Galland A, Lunebourg A, Flecher X, Argenson JN. Titanium-titanium modular neck for primary THA. Result of a prospective series of 170 cemented THA with a minimum follow-up of 5 years. Orthop Traumatol Surg Res 2015; 101 (2) 137-142
    CrossrefPubMedGoogle Scholar
  • 73 Singh JA, Schleck C, Harmsen S, Lewallen D. Clinically important improvement thresholds for Harris hip score and its ability to predict revision risk after primary total hip arthroplasty. BMC Musculoskelet Disord 2016; 17: 256
    CrossrefPubMedGoogle Scholar
  • 74 Zeng Y, Qi X, Feng W , et al. One-sided hip-preserving and concurrent contralateral total hip arthroplasty for the treatment of bilateral osteonecrosis of the femoral head in different stages: short-medium term outcomes. BMC Musculoskelet Disord 2015; 16: 133
    CrossrefPubMedGoogle Scholar