FEMORAL HEAD OSTEONECROSIS: WHY CHOOSE FREE

VASCULARIZED FIBULA GRAFTING

ANASTASIOS V. KOROMPILIAS, M.D.,1* ALEXANDROS E. BERIS, M.D.,1 MARIOS G. LYKISSAS, M.D.,1
IOANNIS P. KOSTAS-AGNANTIS, M.D.,1 and PANAYIOTIS N. SOUCACOS, M.D.2

Osteonecrosis of the femoral head is a disease in which bone death occurs and usually progresses to articular incongruity and subsequent
osteoarthritis. To delay the process of the disease and the conversion to total hip arthroplasty, many surgical techniques have been
described. Core decompression, nonvascularized autologous bone grafts, porous tantalum implant procedure, and various osteotomies
have been used for the management of early precollapse stage osteonecrosis of the femoral head. However, none of these procedures is
neither entirely effective nor can obtain predictable results. With the progress of microsurgery, the implantation of a free vascularized fibula
graft to the necrotic femoral head has provided the most consistently successful results. Although the procedure is technically demanding,
there is growing recognition that the use of free vascularized fibula graft may improve patient quality of life by functional improvement and
pain alleviation. The success of the procedure is related to decompression of the femoral head, excision of the necrotic bone, and addition
of cancellous bone graft with osteoinductive and osteoconductive properties, which augments revascularization and neoosteogenesis of
the femoral head. Free vascularized fibula graft, especially in younger patients, is a salvaging procedure of the necrotic femoral head in
early precollapse stages. In postcollapse osteonecrosis, the procedure appears to delay the need for total hip arthroplasty in the majority
of patients. The purpose of this review article is to update knowledge about treatment strategies in femoral head osteonecrosis and to
compare free vascularized fibula grafting to traditional and new treatment modalities. V C 2010 Wiley-Liss, Inc. Microsurgery 31:223–228,

2011.

Osteonecrosis of the femoral head constitutes a multifac-
torial disease mainly affecting young adults. Pain, dysfunc-
tion of the hip, and increasing patient disability compose
the natural history of this clinical entity. The fracture of
the subchondral bone, the articular cartilage collapse, and
finally the osteoarthosis of the hip joint are radiographic
features that characterize the process of this disease.
Despite the large number of hypotheses that have
been proposed, there continues to be a lack concerning
the pathogenesis of the disease. Various factors have
been associated with osteonecrosis of the femoral head.
The interaction between these factors and a genetic pre-
disposition may trigger the sequence that leads to disease
development.1 The lesion has been attributed among
others to corticosteroid administration, alcohol, trauma,
and pregnancy.2 Patients with clinical entities such as
sickle cell anemia, systemic lupus erythematosus, and
inflammatory bowel disease are in high risk for osteonec-
rosis development.2 Autosomal dominant inheritance of
osteonecrosis has been linked with mutations in the type
II collagen gene (COL2A1).3 Certain genetic polymor-
phisms of genes affecting the coagulation and fibrinolytic
system have also been associated with sporadic cases of
osteonecrosis.4–8 The underlying pathophysiology should
1
Department of Orthopaedic Surgery, University of Ioannina, School of Medi-
cine, Ioannina, Greece
2
Department of Orthopaedic Surgery, University of Athens, School of Medi-
cine, Athens, Greece
*Correspondence to: Anastasios V. Korompilias, M.D., Department of Ortho-
paedic Surgery, University of Ioannina School of Medicine, Ioannina 45110,
Greece. E-mail: koroban@otenet.gr
Received 11 August 2010; Accepted 11 August 2010
Published online 25 October 2010 in Wiley Online Library (wileyonlinelibrary.
com). DOI 10.1002/micr.20837
V
C 2010 Wiley-Liss, Inc.
be taken under consideration during decision making hi-
erarchy, used for the management of patients with osteo-
necrosis of the femoral head.
If possible, primary therapeutic strategies are focused
on femoral head preservation, with arrest of the develop-
ment of osteonecrosis as well as repair of it. When osteo-
arthritic changes are present, total hip replacement is
unavoidable. However, to delay the process of the dis-
ease, no consensus exists on how this should be best
accomplished surgically. Core decompression, various os-
teotomies, and nonvascularized autologous bone grafts
have been used for the management of osteonecrosis of
the femoral head.9–16 The relative efficacy of these treat-
ment options is difficult to evaluate because prospective
controlled studies in the literature are limited. Free vascu-
larized fibula grafting is the author’s preferred method
for the management of femoral head osteonecrosis, per-
formed in more than 300 patients, during the past 20
years. The purpose of this review article is to update
knowledge about treatment strategies in femoral head
osteonecrosis and to compare free vascularized fibula
grafting to traditional and new treatment modalities.
Free Vascularized Fibula Grafting for Femoral
Head Osteonecrosis
In osteonecrosis, as the subchondral bone is itself ne-
crotic and cannot contribute to union, the viability of the
graft is particularly important. With the nutrient blood
supply preserved, free fibular graft demonstrates osteoin-
ductive, osteoconductive, and osteogenetic properties.
Fibular osteocytes and osteoblasts can survive, and incor-
poration of the graft to the recipient bone of the femoral
224 Korompilias et al.
head is facilitated without the usual replacement of the
graft by creeping substitution. The rich vascularity and
biologic potential of the fibular graft allows to achieve
callus formation from the purposely exposed cortex and
the cambial layer of the periosteum of the cephalad end
of the graft to the cancellous bone and the remaining
subchondral bone of the osteonecrotic femoral head.
Osteonecrosis of the femoral head progress to collapse
and articular incongruity in up to 70–80% of all cases.17 It
has been demonstrated that free vascularized fibula graft-
ing is a valuable treatment option for femoral head col-
lapse prevention and hip function improvement in patients
with precollapse osteonecrosis.18–25 According to Urbaniak
et al.,25 the probability for conversion to total hip arthro-
plasty within 5 years after free vascularized fibular graft-
ing was lower in precolapse stages (11, 23, 29, and 27%
for the stage II, III, IV, and V hips, respectively). Simi-
larly, Sotereanos et al.24 showed that the probability of
conversion to total hip arthroplasty within an average of
5.5 years after free vascularized fibula grafting was 28%
for stage II hips and 38% for stages III and IV hips. Mali-
zos et al.23 further demonstrated improved radiographic
appearance of the femoral head core and hip function
improvement in all patients operated on at a precollapse
stage of the disease. When compared with other methods,
such as core decompression, conventional bone graft, and
osteotomies, free vascularized fibula provides the most
consistently successful results. In those patients who are
operated on in a precollapse stage, it should be considered
as salvage procedure with functional recovery and almost
complete relief of pain. According to Berend et al.,26 this
method may also be a worthwhile procedure in patients in
postcollapse stage of the disease (stage IV, Steinberg clas-
sification). The technique of free vascularized fibula graft-
ing does not violate the joint capsule as the other bone
grafting procedures (pedicled iliac crest graft and quadra-
tus femoris pedicle graft) do.27 Finally, conversion to a
total hip arthroplasty can be easily made, as free vascular-
ized fibula grafting minimally alters the technique for pri-
mary implant arthroplasty.
The success of the procedure is related to multiple fac-
tors: 1) decompression of the femoral head, which may halt
the ischemia due to increased intraosseous pressure; 2)
excision of the necrotic bone underneath the weight-bearing
region that might inhibit revascularization of the femoral
head; 3) buttress of the articular surface with the vascular-
ized fibular graft by primary callus formation augmented
with additional cancellous bone graft, which has osteoin-
ductive and osteoconductive factors; and 4) protection of
the healing construct by a period of limited weight-bearing.
Operative Technique
With the patient in the lateral decubitus position, the
affected hip is exposed through a curved anterolateral
Microsurgery DOI 10.1002/micr
incision. An interval is created between the tensor fascia
lata and the gluteus medius followed by dissection
between the rectus femoris and the vastus intermedialis.
The lateral aspect of the proximal femur is exposed and
the ascending branch of the lateral circumflex artery with
its two accompanying veins is prepared for the anastomo-
ses with the peroneal vessel pedicle. Recently, the lateral
circumflex femoral artery turnover technique has been
described. Using this method, a vessel diameter of
5
mm is obtained providing a good match with the pero-
neal vessels.28
The ipsilateral fibula is exposed through a lateral inci-
sion, by a second surgical team working simultaneously
with the hip team. The middle third of the fibula, con-
taining the nutrient vessels is harvesting. The length of
the fibula graft is based on the length of the femoral
head channel.
A Steinmann pin is directed within the osteonecrotic
lesion from the lateral aspect of the greater trochanter
under direct fluoroscopic control. With the Steinmann pin
as a guide, a cylindrical tunnel of 16–18 mm diameter is
made by progressive reaming extending as much as 5
mm of the articular surface. The completion of the tunnel
is followed by necrotic bone removal. A long curette is
used for this purpose. Cancellous bone from the reaming
procedure is finger packed into the core channel. The per-
iosteum of the end of the fibula graft to be implanted is
reflected and sutured. The fibula graft is then ready to be
inserted into the cylindrical tunnel within the femoral
head. The correct placement is confirmed with the image
intensifier C-arm. Stabilization of the graft is accom-
plished using a 1.5-mm Kirschner wire made from tita-
nium. Microsurgical techniques are used for artery and
vein end-to-end anastomoses.
Ambulation is initiated on the third postoperative day.
The patient is instructed to use two crutches with non-
weight-bearing in the operative extremity for 8 weeks
and then to gradually increase weight bear until full
weight-bearing at 6 months. Follow-up clinical and radio-
graphic examinations should be performed at 3 months, 6
months, and yearly thereafter.
Free Vascularized Fibula Graft Versus
Nonvascularized Autogenous Grafts
Nonvascularized bone grafting, as was first described
by Phemister,29 has been extensively used in the treat-
ment of osteonecrosis of the femoral head with various
results. Dunn and Grow30 studied 23 hips with osteonec-
rosis of the femoral head, which were treated with
Phemister-type tibial grafts in 20 cases and iliac grafts in
three cases. They concluded that this technique is indi-
cated only in the early stages of the disease when radio-
graphic evaluation shows normal head contour. Similarly,
Nelson and Clark31 in a retrospective study of 40

patients, who underwent 52 Phemister bone grafting pro-
cedures with a minimum follow-up of 2 years, demon-
strated that Phemister technique should not be performed
once if subchondral collapse is present.
In a retrospective cohort study from two institutions
in different countries, Plakseychuk et al.32 compared the
clinical results of vascularized fibular grafting and non-
vascularized fibular grafting. Two groups of 50 hips each
were matched by the stage, the size, the etiology of the
lesion, and the mean preoperative Harris hip score. The
improvement of the mean Harris hip score for the hips
that were treated with vascularized fibular grafting and
the hips that were treated with nonvascularized fibular
grafting was 70 and 36%, respectively. Furthermore, the
7-year rate of survival of the stage I and II hips was 86%
after treatment with free vascularized fibular grafting
compared with 30% after nonvascularized fibular
grafting.
In a more recent study, Kim et al.33 evaluated the
results of vascularized fibular grafting and nonvascular-
ized fibular grafting in a prospective case-controlled
study. They matched 23 hips with large osteonecrotic
lesion of the femoral head (IIC to IVC, according to
Steinberg classification system) that were managed with
vascularized fibular grafting to a group of 23 hips that
were treated with nonvascularized fibular grafting accord-
ing to the etiology, stage, and size of the lesion. At a the
4 year follow-up period, the improvement of the mean
Harris hip score for the hips that were treated with vascu-
larized fibular grafting and the hips that were treated with
nonvascularized fibular grafting was 70 and 35%, respec-
tively. The rates of radiographic progression and collapse
were significantly lower in the group treated with a vas-
cularized fibular graft. The authors concluded that vascu-
larized fibular grafting has better clinical and radiographic
results than nonvascularized fibular grafting in precol-
lapse hips, particularly those with Steinberg stage IIC
disease.
Free Vascularized Fibula Graft Versus Core
Decompression
Core decompression with or without bone grafting for
structural support was the most common procedure per-
formed for the early stages of osteonecrosis of the femo-
ral head.34–36 Core decompression, which was originally
described as a diagnostic technique, has been employed
for more than three decades as therapeutic procedure. As
treatment option is thought to relieve from pain, improve
vascularity of the femoral head, and slow the progression
of osteonecrosis through the decrease in intraosseous
pressure. However, despite numerous studies, no general
consensus that exists on the efficacy of the procedure
continues to be controversial with quite unpredictable
results.37 In a comparative study, Aaron et al.38 showed
Femoral Head Osteonecrosis 225
radiographic progression of the osteonecrosis in 64% of
the hips that have been treated with core decompression
and only in 39% of the hips that have been treated with
pulsed electromagnetic fields. However, when patients
with osteonecrosis of the femoral head who have been
treated with core decompression were compared with
patients who have had conservative treatment, radio-
graphic progression of the disease was observed in 31
and 77% of the hips, respectively. Mont et al.39 in a
meta-analysis of 1,206 hips treated with core decompres-
sion demonstrated progression of the osteonecrosis in 434
hips (36%).
Scully et al.40 performed statistical comparison
between 72 patients (98 hips) who have been treated with
core decompression and 480 patients (614 hips) in whom
free vascularized fibula grafting had been performed for
the management of Ficat stage I to III osteonecrosis of
the femoral head. None of the 11 Ficat stage I hips were
eventually required for total hip arthroplasty, irrespective
of the method of treatment. At 50 months, the rate of
survival of the stage II hips that have been treated with
free vascularized fibula grafting was 89% compared with
65% of those that have been treated with core decom-
pression. Similarly, the stage III hips that have been
treated with free vascularized fibula grafting had an 81%
rate of survival at 50 months compared with 21% for
those with core decompression. The authors supported
that core decompression alone inadequately addresses the
bone pathology. Therefore, the application of vascularized
fibular cortical strut to the subchondral bone may be
superior to core decompression alone in terms of mechan-
ical support and biological enhancement of the necrotic
femoral head.
Free Vascularized Fibula Graft Versus
Osteotomies
Angular intertrochanteric or rotational osteotomies of
the proximal femur are aimed at shifting the affected
areas of the femoral head away from the major weight-
bearing regions of the joint.41 Although rotational osteot-
omies may have a role in the management of selected
patients, they are technically demanding procedures with
inconsistent results and often alter gait pattern.1,42–44
There is an increased risk of nonunion with the overall
complication rate to be as high as 5%.42 In addition, a
previous rotational osteotomy may significantly compli-
cate subsequent total hip replacement. Total hip arthro-
plasty following a rotational transtrochanteric osteotomy
is technically difficult and is usually associated with
increased operative time, increased blood loss, and high
infection rates.43,44
Varus or valgus intertrochanteric osteotomies are less
demanding than rotational osteotomies with success rates
ranging between 40 and 96%.1 Candidates for these oste-
Microsurgery DOI 10.1002/micr
226 Korompilias et al.
otomies are young patients with unilateral small size
lesions and with a good preoperative range of motion.1
Osteonecrosis in precollapse stages and no association
with corticosteroids administration has better results when
treated with angular osteotomies.
Because of variable outcomes, the high complication
rates, and the increased technical demands of a subse-
quent total hip replacement, these procedures have fallen
out of favor. Recently, a proximal femoral osteotomy
combined with free vascularized fibular grafting has been
reported for treatment of osteonecrosis of the femoral
head caused by nonunion of the femoral neck.45
Free Vascularized Fibula Graft Versus
Porous Tantalum Implant
Investigators have shown rapid and extensive bone
ingrowth associated with porous tantalum acetabular
cups.46,47 The implant is characterized by an
80% po-
rous material, with fully interconnected pores, and osteo-
conductive microtexture.48,49 Advocators of this proce-
dure support that porous tantalum implant, by having
elastic properties that are similar to that of cancellous
bone, may provide mechanical support and function as a
structural graft and at the same time allow bone growth
into the necrotic area of the femoral head.48,49
In a recent study, 17 porous tantalum implants that
were retrieved at the time of conversion to total hip arthro-
plasty were histopathologically analyzed.50 All of them
had been used for the management of stage II osteonecro-
sis of the femoral head according to Steinberg classifica-
tion system. Osteonecrotic lesions were present in 14 of
the 15 specimens (93%) that had been transected in situ
near the base of the femoral head. Although in all cases
the implant was within the lesion site, the retrieved
implants were associated with insufficient mechanical sup-
port of the subchondral bone and little bone ingrowth. In
contrast to previous animal studies, limited bone ingrowth
into the implants was found in both the femoral head and
the nonaffected region of the femoral neck. In nine of the
15 retrieved implants, (60%) residual necrotic bone and
subchondral collapse of the femoral head was noticed.
An interesting finding was the disproportion between
the diameter of the implant (10 mm) and the extent of
the osteonecrotic lesion.50 Only a mean of 21% of the
area of the lesion was found to be occupied by the po-
rous tantalum implant. On the other hand, free vascular-
ised fibula graft with a diameter ranging from 16 to 18
mm provides more sufficient mechanical support neces-
sary to prevent subchondral collapse.
The surgical technique used to implant the porous
tantalum biomaterial does involve neither debridement of
the necrotic bone in the femoral head nor placement of
bone graft into the core channel. In contrast, successful
treatment of osteonecrosis with a free vascularized fibula
Microsurgery DOI 10.1002/micr
graft involves meticulous removal of any necrotic bone
with a long curette and adjuvant cancellous bone grafting,
obtained from the reaming procedure, into the core chan-
nel and guarantees a supply of blood to the healing ne-
crotic femoral head.
It is already known that porous tantalum implant pro-
cedure is mainly indicated for the management of early
stage osteonecrosis of the femoral head in patients who
do not have chronic systemic disease.51 However, taking
into account the aforementioned, we may also suggest
that the present implant design is inappropriate for lesions
larger than 10 mm. Nevertheless, the surgical technique
currently used is not associated with sufficient bone
ingrowth and adequate mechanical support of the sub-
chondral bone.
Free Vascularized Fibula Graft Versus
Total Hip Replacement
Approximately 10% of all total hip arthroplasties per-
formed in the United States are due to osteonecrosis.52
Primary total hip replacement, when collapse and defor-
mation of the femoral head occur, is an excellent option
in the older patient. Nevertheless, several studies have
shown more successful clinical and radiographic results,
when total hip arthroplasties with second-generation and
third-generation prosthetic devices have been used for the
management of osteonecrosis of the femoral head.53–56
However, in the younger age group of patients, arthro-
plasty with its limited life span and increased morbidity
is often an unfavorable option.57,58 Surgical alternatives
for young patients with large osteonecrotic lesions are
limited femoral resurfacing arthroplasty and bipolar hemi-
arthroplasty. Candidates for these procedures are patients
with Ficat stage III disease, change in femoral head con-
tour of >2 mm, normal acetabular cartilage, and a com-
bined necrotic angle of >2008 or >30% involvement.1
Even in those patients with more advanced osteonec-
rosis including those patients with collapse of the articu-
lar surface, free vascularized fibula grafting may be of
benefit by prolonged reduction of symptoms and post-
ponement of total hip arthroplasty.26 Even in the case of
osteonecrosis, secondary to traumatic hip dislocation, free
vascularized fibula grafting has been shown to decrease
the need of total hip arthroplasty.59 In 28 of 35 patients
who underwent free vascularized fibular grafting for
osteonecrosis following traumatic hip dislocation, Harris
Hip scores tended to show improved hip function and
only eight patients required conversion to total hip arthro-
plasty at an average of 45 months postoperation.59
CONCLUSION
With the progress of microsurgery in the last 30
years, the implantation of a free vascularised fibula graft

is an effective means of salvaging the necrotic femoral
head. The presence of symptomatic stage II to IV lesion
in a patient younger than 50 years is considered the main
indication for fibula grafting. Narrowing of the joint
space and acetabular involvement are contraindications
for femoral head preserving surgery. Although there is
not yet a consistently satisfactory method for the treat-
ment of osteonecrosis of the femoral head, the salvage
technique of free vascularized fibular graft has been more
successful from any other procedure.
The success of the procedure is related to decompres-
sion of the femoral head, excision of the necrotic bone,
and addition of cancellous bone graft with osteoinductive
and osteoconductive properties, which augments revascu-
larization and osteogenesis of the femoral head. Free vas-
cularized fibula graft transfer, especially in younger
patients, in early precollapse stages of osteonecrosis is a
salvage procedure of necrotic femoral head. Finally, in
patients with postcollapse osteonecrosis, the procedure
appears to delay hip arthroplasty in the majority of
patients, and it may eliminate the need for eventual
arthroplasty in many of them.
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