Treatment of avascular necrosis of the femoral head with vascularized fibular transplant

Two hundred twenty-eight hips in 187 patients with avascular necrosis of th e femoral head were treated with vascularized fibular transplant from March 1989 to March 2000. The etiologic factors associated with the disease incl uded corticosteroids in 84 patients (44%; 101 hips, trauma in 25 patients ( 13%; 29 hips), alcohol abuse in 24 patients (12%; 28 hips), and 41 hips (18 %) were classified as idiopathic. Systemic disorders, including systemic lu pus erythematosus, sickle cell anemia, inflammatory bowel disease, pregnanc y, and dysbaric disease were observed in 12, nine, four, three, and one hip (s), respectively. Of the 228 hips operated on, 184 hips (152 patients) wer e assessed postoperatively with followup ranging from 1 to 10 years (mean, 4.7 years). Using the Steinberg classification system, 39 hips (21%) were i n Stage II; 45 hips (25%) were in Stage III; 77 hips (42%) were in Stage IV ; and 23 hips (12%) were in Stage V, Of the 184 hips treated, 101 (54%) rem ained stable postoperatively, whereas 69 (38%) had progression, and 14 hips (8%) were converted to total hip arthroplasty. Of the 69 hips that had pro gression, 44 (64%) did not progress until 6 to 10 years after the procedure , whereas 25 (36%) progressed within the first 5 years postoperatively. The best results were obtained in patients with Stage II osteonecrosis in whom 95% of the hips did not progress postoperatively. In contrast, only 39% of the hips in patients with Stage V osteonecrosis remained stable. Preoperat ive and postoperative clinical evaluation using the Harris hip score showed an increase from 85 to 96 points in hips with Stage II disease; from 74 to 91 points in hips with Stage III disease; from 69 to 85 points in hips wit h Stage IV disease; and from 61 to 76 in hips with Stage V disease. The cur rent results show that the vascularized fibular graft is an excellent proce dure for the precollapse stages and a valuable alternative for patients wit h Stages III, IV, and V of the disease.