Unilateral free vascularized fibula shared for the treatment of bilateral osteonecrosis of the femoral head.

Between June 2007 and May 2008, 21 patients with bilateral osteonecrosis of the femoral head were surgically treated with implantation of free vascularized fibula obtained from the unilateral donor site. All patients were followed up clinically and radiographically for an average of 3.5 years. The evaluation included operative duration, blood loss, Harris hip score, incidence of complications, and radiological examinations. The time for fibular harvesting was 20min on average. Total operative duration was 100-240min, with an average of 150min. Blood loss averaged 300ml. All transplanted fibula integrated well to the femoral head 3.5years postoperatively with no severe complications observed. The results revealed that unilateral free vascularized fibula is effective for the treatment of bilateral osteonecrosis of the femoral head.

Modified surgical techniques of free vascularized fibular grafting for treatment of the osteonecrosis of femoral head: results from a series of 407 cases.

The goal for treatment of osteonecrosis of the femoral head (ONFH) is to relieve pain, preserve the contour of the femoral head, and delay the need for total hip arthroplasty. The free vascularized fibular grafting (FVFG) has been shown to support the subchondral architecture as well as restore local circulation for the necrotic femoral head in treatment of ONFH. This report aimed to present the clinical results of the use of a modified surgical technique of FVFG for treatment of ONFH. Four hundred and seven patients with 578 hips of ONFH were included. The patients' average age was 36.7 years old (ranging 19-55 years old). The disease was staged from II to V based on the Steinberg classification system. By the modified procedure, the vascularized fibular graft was harvested via a lateral incision with fibular osteotomy prior to the exposure of the vascular pedicle, and the removal of necrotic tissue and inset of graft were performed through an anterior approach. The operative time averaged 90 min for unilateral ONFH (ranging 75-110 min) and 190 min for simultaneous treatment of bilateral ONFH (ranging 160-230 min). The average length of follow-up was 5.0 years (ranging 3-10 years). The complications included one infection in one case, temporary loss of sensation of the thigh in eleven cases, and restricted motion of the great toe in nine cases. The Harris hip score of patients improved from 65.0 to 86.9 on average. Radiographic evaluation showed no changes in 331 hips (57.3%), improvement in 195 hips (33.7%) and necrosis progression in 52 hips (9.0%). Twenty-three hips (4.0%) in 20 patients had total hip arthroplasty during the period. These results show that the modified technique of the use of FVFG for treatment of ONFH yields similar postoperative results in comparison to the traditional method.

Free vascularized fibular grafting benefits severely collapsed femoral head in concomitant with osteoarthritis in very young adults: a prospective study.

Although free vascularized fibular grafting (FVFG) has been successfully employed for precollapsed osteonecrosis of the femoral head (ONFH), there are few reports concerning its radiographic and functional results for ONFH concomitant with osteoarthritis (OA) of the hip. In the current study, 12 patients with OA induced by traumatic ONFH were enrolled, with FVFG employed as the treatment protocol. The collapsed step of the cartilage surface was measured and compared with the postoperative value, and the Merle d'Aubigné scoring system was used to evaluate preoperative and postoperative status of the hip joint. The collapsed step disappeared, and sphericity of the femoral head could be restored at an average duration of 56 months postoperatively in seven patients. With regard to the severity of hip OA, six were improved to Grade 1 and one to Grade 2. In terms of functionality, all patients with a restored femoral head experienced postoperative improvement in pain relief, mobility, and functional capacity. The average Merle d'Aubigné score increased from 6.0 to 16.9 postoperatively (p < 0.001). In conclusion, for traumatic ONFH concomitant with OA, FVFG can confer benefits in the form of restoration of the contour of the femoral head and improvement in joint function.

Injury-to-surgery interval does not affect the occurrence of osteonecrosis of the femoral head: a prospective study in a canine model of femoral neck fractures.

BACKGROUND: It is controversial whether an early reduction and internal fixation can reduce the occurrence of femoral neck fracture-induced osteonecrosis of the femoral head (ONFH). This prospective study was designed to reflect the relationship between injury-to-surgery interval (ISI) and traumatic ONFH based on a canine model of femoral neck fractures. MATERIAL/METHODS: Twenty-four dogs were equally divided randomly into 3 groups. A lateral L-shape approach centered left great trochanter was used for exposure of the femoral neck. A low-speed drill was used for making displaced fractures in the narrow femoral neck, with the femoral head kept in situ with ligamentum teres intact. In Group A, the fracture was immediately reduced and fixed with 3 parallel pins; while the operation was done 3 days later in Group B, and 3 weeks later in Group C. Another 2 dogs had their fractures untreated. Postoperatively, all dogs were fed separately and received regular x-ray examination. Left femoral heads were harvested for histological examination with a postoperative follow-up of 3.5 months. RESULTS: The canine model of femoral neck fractures could be achieved successfully. Radiological signs of post-fracture ONFH could not be detected at intervals of 2 weeks, 4 weeks, 1 month and 2 months. Histologically, there were 2 cases with ONFH in Group A, 1 case in Group B, and 2 cases in Group C. The difference had no statistical significance. For untreated fractures, obvious ONFH could be found radiologically. CONCLUSIONS: A shorter ISI may not reduce the incidence of fracture-induced ONFH, which suggests that intrinsic factors play an important role in the occurrence of ONFH.

Internal fixation using fully threaded cannulated compression screws for fresh femoral neck fractures in adults.

OBJECTIVES: Internal fixation with multiple cannulated compression screws is an optional treatment for femoral neck fracture. Recently, fully threaded cannulated compression screws (FTCCS) have been introduced to fix fresh femoral neck fractures (FNF). The purpose of this study was to investigate the effectiveness of FTCCS. PATIENTS AND METHODS: Patients with FNF fixed by multiple FTCCS from February 1st, 2014 to August 31st, 2017 were included in this study. They were followed for at least 12 months postoperatively. Nonunion, osteonecrosis of the femoral head (ONFH), fixation failure, reoperation, and femoral neck shortening (FNS) were used to evaluate the outcomes. Risk factors including age, sex, fracture side, fracture displacement, fracture stability, fixation configuration, and screw numbers were analyzed. RESULTS: A total of 113 patients including 67 males and 46 females with an average age of 48.4 ± 13.4 years were included. The mean duration of follow-up was 27.1 months (range: 12-51 months). The incidence of nonunion, ONFH, fixation failure, and reoperation was 15.9%, 22.1%, 8.8%, and 24.8%, respectively. The rates of nonunion and reoperation were significantly higher in displaced fractures and unstable fractures. And patients with an unstable fracture had a higher risk of internal fixation failure. The median length of FNS was 2.9 mm (interquartile range: 0.9-6.5 mm, range: 0-17.5 mm). Age was a significant risk factor for FNS. CONCLUSIONS: The screw fixation method with FTCCS provided encouraging clinical results which may be a rational choice for the treatment of fresh FNF. Displaced fractures and unstable fractures were attributed to the higher incidence of complications. TRIAL REGISTRATION: ChiCTR, ChiCTR1800017200. Registered 17 July 2018-Retrospectively registered, http: www.chictr.org.cn/showprojen.aspx?proj=29182 .

Autologous Costal Cartilage Grafting for a Large Osteochondral Lesion of the Femoral Head: A 1-Year Single-Arm Study with 2 Additional Years of Follow-up.

BACKGROUND: There is currently no ideal treatment for osteochondral lesions of the femoral head (OLFH) in young patients. METHODS: We performed a 1-year single-arm study and 2 additional years of follow-up of patients with a large (defined as >3 cm 2 ) OLFH treated with insertion of autologous costal cartilage graft (ACCG) to restore femoral head congruity after lesion debridement. Twenty patients ≤40 years old who had substantial hip pain and/or dysfunction after nonoperative treatment were enrolled at a single center. The primary outcome was the change in Harris hip score (HHS) from baseline to 12 months postoperatively. Secondary outcomes included the EuroQol visual analogue scale (EQ VAS), hip joint space width, subchondral integrity on computed tomography scanning, repair tissue status evaluated with the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and evaluation of cartilage biochemistry by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping. RESULTS: All 20 enrolled patients (31.02 ± 7.19 years old, 8 female and 12 male) completed the initial study and the 2 years of additional follow-up. The HHS improved from 61.89 ± 6.47 at baseline to 89.23 ± 2.62 at 12 months and 94.79 ± 2.72 at 36 months. The EQ VAS increased by 17.00 ± 8.77 at 12 months and by 21.70 ± 7.99 at 36 months (p < 0.001 for both). Complete integration of the ACCG with the bone was observed by 12 months in all 20 patients. The median MOCART score was 85 (interquartile range [IQR], 75 to 95) at 12 months and 75 (IQR, 65 to 85) at the last follow-up (range, 24 to 38 months). The ACCG demonstrated magnetic resonance properties very similar to hyaline cartilage; the median ratio between the relaxation times of the ACCG and recipient cartilage was 0.95 (IQR, 0.90 to 0.99) at 12 months and 0.97 (IQR, 0.92 to 1.00) at the last follow-up. CONCLUSIONS: ACCG is a feasible method for improving hip function and quality of life for at least 3 years in young patients who were unsatisfied with nonoperative treatment of an OLFH. Promising long-term outcomes may be possible because of the good integration between the recipient femoral head and the implanted ACCG. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Replantation of above-knee amputation: a surviving but dysfunctional case needing secondary amputation.

Above-knee amputations are rare injuries that need emergent replantation or primary amputation. Although survival could be achieved in selective cases, postoperative function of the affected limb is usually unsatisfactory and a late amputation has to be performed for poor prognosis or severe complications. Experience of the surgical team may play an important role in primary decision making, which leads us to report one case of above-knee replantation with poor postoperative function and needing a late amputation. Scoring systems, expected results based on our case, and a brief review of literature concerning above-knee replantations are discussed.

Combination of modified free vascularized fibular grafting and reverse Less Invasive Stabilization System (LISS) for the management of femoral neck nonunion in patients thirty years of age or younger.

Femoral neck nonunion (FNN) is a potential complication in patients with displaced femoral neck fractures, occurring in 33%. This may lead to early hip dysfunction or arthroplasty. Combination of modified free vascularized fibular grafting (FVFG) and a reverse LISS may provide a reasonable means to salvage a painless, functional and native hip. Between August 2010 and August 2012, sixteen patients with femoral neck nonunion were treated with a combined procedure involving modified free vascularized fibular grafting and a reverse LISS. The average age of them is 20.3 years (range 12.0-28.0 years). After removing old implants, the nonunion site was debrided, reduced and fixed with a LISS. The fibular grafts were compacted into a trough in the femoral neck. The Harris Hip score system was used to assess hip function and anteroposterior and frog-lateral hip roentgenograms were used to evaluate bone healing. All femoral neck nonunion healed without severe complications. The mean follow-up time was 32.9 months (range 23.0-47.0 months) and the average union time was 7.6 months (range 5.0-10.0 months). All coxa vara deformities and retroversions of the femoral head were corrected. The Harris hip scores (HHS) were improved 36.6 points on average (59.6 points preoperatively to 96.2 points postoperatively). No incidences of osteonecrosis of the femoral head were observed. The combined modified FVFG and reverse LISS plating is a suitable procedure for the management of femoral neck nonunion in patients younger than 30 years, especially for those patients with a revision history.

Prevalence of clinical anxiety, clinical depression and associated risk factors in chinese young and middle-aged patients with osteonecrosis of the femoral head.

OBJECTIVE: To investigate the prevalence of clinical anxiety and clinical depression in Chinese young and mid-aged patients with osteonecrosis of the femoral head (ONFH) and to analyze their potential risk factors. METHODS: Two hundred and sixteen Chinese patients with ONFH were consecutively enrolled in this cross-sectional study from January 2010 to December 2010. The Zung self-rating anxiety scale (SAS) and the Zung self-rating depression scale (SDS) were used to assess the prevalence of clinical anxiety and clinical depression. An additional questionnaire containing seventeen items of potential risk factors was completed by all patients. Binary logistic regression analysis was employed to reveal potential risk factors of anxiety and depression. RESULTS: The prevalence of clinical anxiety and clinical depression was 20.4% and 21.8% in Chinese young and middle-aged patients with ONFH, respectively. Binary regression analysis showed that independent risk factors correlated with high incidence of clinical anxiety included involved femoral head (OR = 3.168, 95% CI: 1.496 - 6.708) and stages of ONFH (ORIV-V / II = 5.383, 95% CI: 1.664-17.416). Independent risk factors correlated with high incidence of depression included gender (OR = 2.853, 95% CI: 1.467-5.778), comorbid diseases (OR = 4.243, 95% CI: 1.940-9.278) and stages of the disease (OR IV-V/II = 16.963, 95% CI: 4.404-65.331). CONCLUSIONS: Patients with bilateral ONFH are inclined to have clinical anxiety, while female patients and patients with comorbid diseases might tend to get clinical depression. Advanced stages of ONFH are independent risk factors for both clinical anxiety and clinical depression.

Pain relief following osteonecrosis of the femoral head treated by free vascularized fibular grafting.

BACKGROUND: Pain is the core and basic problem in the treatment of osteonecrosis of the femoral head (ONFH). However, it is unclear about the status of pain relief following ONFH treated by free vascularized fibular grafting (FVFG) and the level of pain relief contributed to clinical results. Therefore, we designed a consecutive and prospective study to investigate post-operative pain relief in the treatment of osteonecrosis of the femoral head by FVFG. METHODS: One hundred and fifty-one patients with unilateral osteonecrosis of the femoral head were enrolled consecutively for current prospective study from January to August of 2006. Patients were managed by modified technique of free vascularized fibular grafting. Pre-operative, post-operative Harris hip score (HHS) and Harris pain score (HPS) were recorded and compared statistically, meanwhile, correlation between disease severity and Harris hip score, Harris pain score were revealed. RESULTS: All patients had an average follow-up of 54.3 months. Post-operative Harris hip score could be improved from 73.7 to 83.5 averagely in stage-II patients, 64.6 to 78.9 in stage-III, and 53.6 to 72.4 in stage-IV. As for Harris pain score, it was elevated from 28.8 to 38.6 in stage-II patients, 25.5 to 36.6 in stage-III, and 21.8 to 34.2 in stage-IV. Taken together, HHS was improved from 67.7 to 80.3 (ΔHHS = 12.6), and HPS was improved from 26.6 to 37.3 (ΔHPS = 10.7) averagely. CONCLUSIONS: Harris pain score could be employed to monitor prognosis of osteonecrosis of the femoral head treated by free vascularized fibular grafting. Improvement of HPS was the heaviest contributor to elevation of HHS, and both of them conceived of a close relationship with disease severity.

Free vascularised fibular grafting combined with a locking plate for massive bone defects in the lower limbs: a retrospective analysis of fibular hypertrophy in 18 cases.

OBJECTIVE: Free vascularised fibular grafting (FVFG) could be a good option for the restoration of massive bone defects in lower limbs when combined with use of a locking plate. The progress of fibular hypertrophy is closely related to regain of function, as well as to prevention of stress fractures. Multiple variables affecting fibular hypertrophy were investigated in the current study to elucidate correlative factors. METHODS: Eighteen patients with a massive bone defect in a lower limb reconstructed by FVFG combined with a locking plate were retrospectively enrolled in the current study. The degree of fibular hypertrophy was calculated based on the measurements from anteroposterior imaging at regular intervals of 3 months, 6 months, 1, 2 and 3 years postoperatively. Repeated measures analysis of variance was employed to evaluate and compare correlative factors including gender (male vs. female), age distribution (<30 years vs. >30 years), site (femur vs. tibia) and length of bone defect (6-10 cm vs. >10 cm), previous number of operations (once vs. more than twice) and concomitant infection (detected vs. non-detected). RESULTS: All defects could be successfully repaired by FVFG and bone union was achieved uneventfully. The degree of fibular hypertrophy was 0.14%, 11.27%, 31.53%, 58.14% and 71.81% retrospectively at the five follow-up time points. Statistical analysis revealed that the above-mentioned factors did not affect the progress of fibular hypertrophy. CONCLUSIONS: FVFG could be a good choice for the reconstruction of massive bone defects when combined with a locking plate. Factors including gender, age distribution, site and length of bone defects, number of previous operations and infection do not impact the progress of fibular hypertrophy, which implies that intrinsic factors might play an important role in restoration.

Early results of reverse less invasive stabilization system plating in treating elderly intertrochanteric fractures: a prospective study compared to proximal femoral nail.

BACKGROUND: Intertrochanteric femur fracture is common in elderly population. Though multiple treatment options are available, the choice of implant remains controversial. The reverse less invasive stabilization system (LISS) plating was introduced for treatment of a patient with ipsilateral intertrochanteric and midshaft femoral fractures. The aim of this research was to compare such technique to intramedullary nailing (proximal femoral nail, PFN) for intertrochanteric fractures. METHODS: Fifty-six patients with an age of at least sixty-five years and an AO/OTA type-A1 or A2 fractures were included and divided into LISS and PFN treatment group. BACKGROUND: parameters, fracture and surgery details were documented. Follow-up time was at least 12 months. Radiology, complication, Harris Hip Score and Rapid Disability Rating Score (RDRS) were recorded to evaluate fixation status and hip function for each patient during follow-up. RESULTS: There was no significant difference between the two groups in surgical time ((48.0 ± 8.6) minutes, vs. (51.8 ± 10.8) minutes, P = 0.3836) and intraoperative blood loss ((149.1 ± 45.1) ml vs. (176.4 ± 25.4) ml, P = 0.0712). The LISS group had less postoperative haemoglobin (Hb) reduction ((10.2 ± 4.5) g/L Hb, vs. (15.1 ± 5.9) g/L Hb, P = 0.0475). There was no complication observed in PFN group. All 31A1 type fracture in LISS group showed 100% maintenance of reduction. One nonunion with locking screw breakage and 2 varus union were found in the LISS group. Postoperative hip function was similar between the two groups. CONCLUSIONS: Though reverse LISS plating may not be recommended as a routine fixation method for elderly unstable intertrochanteric fractures compared to PFN, it may possibly be reserved for rapid fixation and damage control in polytrauma patients and ORIF of subtrochanteric and reverse oblique intertrochanteric fractures.

Free vascularized fibular grafting in combination with a locking plate for the reconstruction of a large tibial defect secondary to osteomyelitis in a child: a case report and literature review.

Although a large skeletal defect secondary to osteomyelitis in children is not an uncommon problem, there are no descriptions of the management of such a defect with a free vascularized fibular graft in combination with a locking plate. We performed such a technique, after radical debridement and systemic antibiotic treatment, on a 13-year-old boy suffering from a large 10 cm tibial defect secondary to osteomyelitis. Primary union of the graft was achieved at 6 months. No recurrence of osteomyelitis occurred in the 29-month follow-up period, and limb salvage and eradication of the infection were achieved successfully.

In vitro evaluation of cytotoxicity of silver-containing borate bioactive glass.

The cytotoxicity of silver-containing borate bioactive glass was evaluated in vitro from the response of osteoblastic and fibroblastic cells in media containing the dissolution products of the glass. Glass frits containing 0-2 weight percent (wt %) Ag were prepared by a conventional melting and quenching process. The amount of Ag dissolved from the glass into a simulated body fluid (SBF), measured using atomic emission spectroscopy, increased rapidly within the first 48 h, but slowed considerably at longer times. Structural and microchemical analysis showed that the formation of a hydroxyapatite-like layer on the glass surface within 14 days of immersion in the SBF. The response of MC3T3-E1 and L929 cells to the dissolution products of the glass was evaluated using SEM observation of cell morphology, and assays of MTT hydrolysis, lactate dehydrogenase release, and alkaline phosphatase activity after incubation for up to 48 h. Cytotoxic effects were found for the borate glass containing 2 wt % Ag, but not for 0.75 and 1 wt % Ag. This borate glass containing up to ∼1 wt % Ag could provide a coating material for bacterial inhibition and enhanced bioactivity of orthopaedic implant materials such as titanium.

Treatment of aseptic nonunion after intramedullary nailing fixation with locking plate.

OBJECTIVE: To evaluate the safety and efficacy of locking plate combined with bone grafting in the treatment of aseptic nonunion following intramedullary nailing fixation of fractures of the long bones. METHODS: Thirty-eight consecutive patients treated in our hospital between January 2004 and December 2006 were included in this retrospective study. The nonunions included 20 femurs, 15 tibias, and 3 humeri. The duration of non-union ranged from 6 to 84 months and 21 (55.3%) of them were located around the metaphysis of the affected long bones. There were 12 women and 26 men with a mean age of 39.2 years (range, 9-70 years). Locking plate combined with bone grafting was the procedure chosen to treat every case of nonunion in this series. The clinical outcomes were evaluated. RESULTS: All patients were followed up for 6-20 months (average 11.6 months). After locking plate fixation combined with bone grafting, union was achieved in all cases, the average healing time being 5.3 months (range, 4-8 months). Infection of the superficial incision occurred in three cases (7.9%) and delayed healing of the incision in one case, all of which healed with no further complications. The function of the adjacent joints was excellent to good in 30 patients (78.9%), fair in 7 (18.4%) and poor in 1 (2.6%) after follow-up. CONCLUSION: Locking plate fixation combined with bone grafting is a highly effective treatment for aseptic nonunions of the long bones after intramedullary nailing fixation, especially in the case of metaphyseal nonunion.