Isolated Scaphoid Dislocation With Radial-Axial Instability: A Treatment Strategy Utilizing Spanning Wrist Plates.

Isolated dislocation of the scaphoid is a rare injury with only a few case reports in the literature. We report on 2 complex scaphoid dislocations demonstrating concomitant axial instability with disruption of the capitohamate articulation as well as the long-ring metacarpal relationship. Both of these patients underwent reduction and fixation using a wrist spanning plate, which was removed approximately 2 months after injury. Follow-up of these patients demonstrated maintenance of reduction, axial stability, and return of painless range of motion.

Outcomes Associated With Scapholunate Ligament Injury Following Intra-Articular Distal Radius Fractures.

PURPOSE: The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF. METHODS: A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain. RESULTS: One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°-68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°-87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°-87°) to 78.5° (range, 71°-107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups. CONCLUSIONS: Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Hand transplantation in the United States: A review of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Database.

Hand transplantation is the most common application of vascularized composite allotransplantation (VCA). Since July 3, 2014, VCAs were added to the definition of organs covered by federal regulation (the Organ Procurement and Transplantation Network (OPTN) Final Rule) and legislation (the National Organ Transplant Act). As such, VCA is subject to requirements including data submission. We performed an analysis of recipients reported to the OPTN to have received hand transplantation between 1999 and 2018. Forty-three patients were identified as having been listed for upper extremity transplantation in the United States. Of these, 22 received transplantation prior to July 3, 2014 and 10 from then to December 31, 2018. Of patients transplanted after 2014, posttransplant functional scores included a decrease in Disabilities of the Arm, Shoulder and Hand questionnaire in 3 of 10 patients, Carroll test scores ranging from 9 to 60 of 99, and monofilament testing with protective sensation achieved in 4 of 6 patients. Complications included rejection in nine recipients with Banff scores from II-IV. One patient experienced graft failure 5 days after transplantation. Of the remaining patients, two were reported as receiving monotherapy and seven receiving dual or triple immunosuppression therapy. The inclusion of VCA in the OPTN Final Rule standardized parameters for safe implementation and data collection.

Validation of the American College of Surgeons National Surgical Quality Improvement Program Risk Model for Patients Undergoing Panniculectomy.

Panniculectomy procedures have been reported to significantly improve quality of life, increase mobility, and improve hygiene in patients with a significant pannus formation. The primary aims of this study were to determine which preoperative risk factors may be used to differentiate postoperative complication rate among patient cohorts and to validate utilization of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk calculator in patients undergoing panniculectomies. METHODS: This retrospective study included all patients who underwent a panniculectomy procedure at our institution from 2005 to 2016. Baseline characteristics, preoperative risk factors, medical comorbidities, and postoperative complications were collected via retrospective chart review. RESULTS: Two hundred sixty-four patients who underwent a panniculectomy were identified. The odds ratios of any postoperative complication were 8.26, 7.76, and 16.6 for patients with classes 1, 2, and 3 obesity, respectively (P < 0.05). Statistical modeling was utilized to evaluate the predictive performance of the ACS-NSQIP Surgical Risk Calculator. We calculated the C-statistic for the ACS-NSQIP model to be only 0.61, indicating that although the model is associated with the risk of complication, it does not have a strong predictive value for this particular procedure. DISCUSSION: This study is one of the first to characterize postoperative complication rate based on extremum of body mass index for panniculectomy patients. Our results show that the utilization of the ACS-NSQIP Risk Calculator in this particular patient population underestimates the complication risk as a whole, which may necessitate the future development of a separate risk assessment model for this procedure.

The impact of perioperative hypothermia on plastic surgery outcomes: a multivariate logistic regression of 1062 cases.

BACKGROUND: Perioperative hypothermia has been associated with increased rates of infection, prolonged recovery time, and coagulopathy. OBJECTIVES: The authors assessed the impact of hypothermia on patient outcomes after plastic surgery and analyzed the impact of prewarming on postoperative outcomes. METHODS: The medical charts of 1062 patients who underwent complex plastic surgery typically lasting at least 1 hour were reviewed. Hypothermia was defined as a temperature at or below 36°C. Postoperative complication data were collected for outcomes including infection, delayed wound healing, seroma, hematoma, dehiscence, deep venous thrombosis, and overall wound problems. Odds ratios (ORs) were estimated from 3 multivariate logistic regression models of hypothermia and one model of body contouring procedures that included prewarming as a parameter. RESULTS: Perioperative hypothermia was not a significant predictor of wound problems (OR = 0.83; P = .28). In the stratified regression model, hypothermia did not significantly impact wound problems. The regression model measuring the interaction between hypothermia and operating time did not show a significantly increased risk of wound problems. Prewarming did not significantly affect perioperative hypothermia (P = .510), and in the model of body contouring procedures with prewarming as a categorical variable, massive weight loss was the most significant predictor of wound complications (OR = 2.57; P = .003). Prewarming did not significantly affect outcomes (OR = 1.49; P = .212). CONCLUSIONS: Based on univariate and multivariate models in our study, mild perioperative hypothermia appears to be independent of wound complications. LEVEL OF EVIDENCE 4: Risk.

Barbed sutures and wound complications in plastic surgery: an analysis of outcomes.

BACKGROUND: Barbed sutures may expedite dermal approximation and improve tissue support while requiring less time and material than conventional sutures. Several types of barbed sutures are available, each with unique advantages. OBJECTIVES: The authors sought to determine whether the incidence of complications differed after wound approximation in plastic surgery when various brands of barbed vs nonbarbed traditional sutures were employed. METHODS: The authors conducted a retrospective review of outcomes in body contouring, free flap, and breast reconstruction. Suture type and closure method were noted for each case. The number of complications after traditional 2-layer closure with nonbarbed sutures was compared with the number of complications after closure via 1- and 2-layer techniques with several brands of barbed sutures, and the brands of barbed sutures were compared with each other. RESULTS: A total of 1011 unique surgical procedures, including 298 procedures with barbed sutures and 713 procedures with nonbarbed sutures, were performed by 5 members of the plastic surgery faculty. The 2-layer technique with barbed sutures was associated with significantly higher rates of wound separation than traditional methods. Excessive erythema along the incision site was significantly more frequent with Quill barbed sutures than with V-Loc barbed sutures. CONCLUSIONS: Barbed sutures were associated with significantly higher rates of minor wound complications, specifically when the 2-layer closure technique was performed. Significantly higher rates of erythema were associated with Quill barbed sutures than with V-Loc barbed sutures. LEVEL OF EVIDENCE 4: Risk.

Effectiveness of prophylactic antibiotics in outpatient plastic surgery.

BACKGROUND: The effectiveness of prophylactic antibiotics has not been established for patients who undergo plastic surgery as outpatients, and consensus guidelines for antibiotic administration in clean-contaminated plastic surgery are not available. OBJECTIVES: In a retrospective study of outpatients, the authors examined preoperative timing of prophylactic antibiotics, whether postoperative antibiotics were administered, and whether any correlations existed between these practices and surgical complications. METHODS: The medical records of 468 plastic surgery outpatients were reviewed. Collected data included preoperative antibiotic timing, postoperative antibiotic use, comorbidities, and complications. Rates of complications were calculated and compared with other data. RESULTS: All 468 patients received antibiotics preoperatively, but only 93 (19.9%) received them ≥1 hour before the initial incision. Antibiotics were administered 15 to 44 minutes before surgery in 217 patients (46.4%). There was no significant difference in complication rates between the 315 patients who received postoperative prophylactic antibiotics (16.2%) and the 153 who did not (20.9%). Comorbidities had no bearing on postoperative complications. CONCLUSIONS: Postoperative antibiotic prophylaxis may be unnecessary for outpatient plastic surgery patients. LEVEL OF EVIDENCE: 3.

The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases.

BACKGROUND: Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity. OBJECTIVE: The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk. METHODS: A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity. RESULTS: A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity. CONCLUSIONS: Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making.

An alternative outpatient care model: postoperative guest suite-based care.

BACKGROUND: Patients recovering from outpatient surgery are responsible for managing their pain, managing ambulation, and even implementing thromboembolism prophylaxis after discharge. Because of the importance of postoperative care to prevent complications, a model of care that helps a patient transition to independent self-care could provide optimal results. OBJECTIVES: The authors investigated the safety and morbidity rate for patients who underwent body contouring procedures and overnight care at an attached, nurse-staffed guest suite facility. METHODS: A retrospective review was conducted of 246 patients who underwent major body contouring and who stayed at least 1 night in the guest suite facility. Major complications included a return to the operating room within 48 hours, major wound infection, and unplanned hospitalization within 48 hours. Minor complications included any postsurgical effect necessitating unplanned physician intervention within the first 30 days. Univariate analyses correlating patient characteristics and complication rates were conducted, as well as comparison of complication rates among same procedures reported in the literature. RESULTS: The complication rate (major and minor complications) was 25.20%. Surgical site infection occurred in 8.13% of patients. The most common wound complication was erythema around the incision site (12.20%). Death, deep vein thrombosis, or pulmonary embolism did not occur. Comparison with relevant results reported in the literature indicated a significant reduction in the occurrence of postoperative venous thromboembolism. CONCLUSIONS: Patient education after surgery is essential to healing and adequate care. The guest suite model provides improved care and education for the patient and family postsurgery by addressing some of the known risk factors of plastic surgery. LEVEL OF EVIDENCE: 4.

Medicaid and Indigent Patients Experience Delayed Fixation of Distal Radius Fractures, Resulting in Worse Consequential Radiographic Outcomes.

Distal radius fractures are the most common upper extremity injury. Patients referred to safety-net tertiary facilities following a fracture experience significant delays in treatment because of financial and language barriers as well as poor access to care at outlying community hospitals. This delay in treatment can affect postoperative functional outcomes and complication rates because of failure to restore anatomic alignment. The purpose of this multicenter study was to assess for risk factors associated with delayed fixation of distal radius fractures and evaluate the impact of delayed treatment on radiographic alignment. Patients with a distal radius fracture treated surgically during a 2-year period were identified. Measures included time from injury to surgery, demographic information, fracture classification, and radiographic parameters. The effect of surgery delay on radiographic outcomes was assessed with delayed surgery defined as 11 or more days out from injury. A total of 183 patients met study inclusion criteria. Medicaid and indigent patients were more likely to experience a delay in surgical treatment. Specifically, 70% of these patients were treated in a delayed fashion. Delayed treatment of 11 days or more was associated with worse radial height and inclination on postoperative radiographic imaging. Medicaid and indigent patients are more likely to experience delayed fixation in the treatment of distal radius fractures. This delayed surgery negatively affects postoperative radiographic outcomes. These findings suggest a need to improve access to care for Medicaid and indigent patients and to proceed with operative intervention within 10 days for distal radius fractures. [Orthopedics. 2024;47(2):e93-e97.].

Wound Complications Following Olecranon Fracture Fixation: Implant and Soft Tissue Considerations.

BACKGROUND: The aim of this multicenter, retrospective, case-control series was to investigate patient- and treatment-specific factors associated with wound breakdown following olecranon fracture fixation.  Methods: We identified patients at our two participating academic centers who were operatively treated for olecranon fractures and those who subsequently underwent a re-operation secondary to postoperative wound breakdown. Demographic and historical information was collected, including BMI and Charlson comorbidity index (CCI) scores. The primary outcome measure was the standardized radiographic measurement of plate prominence and soft tissue thickness posterior to the plate tip.  Results: We identified 32 patients who underwent internal fixation and subsequent wound breakdown. This was compared to a cohort of 35 matched controls that did not have wound issues. Cases with wound breakdown were of higher energy, nine being open cases compared to two in the control group (p<0.05). No differences were identified in plate prominence, soft tissue thickness, and plate type.  Conclusions: Wound breakdown following olecranon fracture fixation is more commonly seen in high-energy open injuries. Plate prominence, soft tissue thickness, and patient-specific factors do not correlate with wound breakdown. Further investigation into the factors influencing plate placement and how they may contribute to wound complications is needed.

Variations in Incidence of Trigger Finger and Response to Corticosteroid Injection after Aromatase Inhibitor Therapy for Breast Cancer.

BACKGROUND: Aromatase inhibitors (AIs), such as letrozole and anastrozole, have been demonstrated to have significant musculoskeletal symptoms in patients. The purpose of this study was to evaluate the effect of specific AI medications on the incidence of trigger finger and independent factors affecting treatment outcomes within this population. METHODS: A retrospective chart review was performed at the authors' institution between the years 2014 and 2018 in patients with the diagnosis of breast cancer. This cohort was then sorted based on receiving medication regimens, trigger finger diagnosis, steroid injections, and need for surgical release of trigger finger. RESULTS: A total of 15,144 patients were included for initial review. The overall rate of trigger finger diagnosis was 2.75% in the entire breast cancer population and 4.5% for patients receiving AI therapy. Patients taking letrozole and anastrozole had an increased odds ratio of 2.0 and 1.7, respectively, for developing trigger finger. Patients who switched between letrozole and anastrozole during treatment had a higher rate of failed steroid injection treatment (45.2% versus 23.5%; P = 0.021). Among patients receiving AI treatment diagnosed with trigger finger, diabetes and hemoglobin A1c level greater than 6.5 were associated with significantly increased rates of failed steroid therapy. CONCLUSIONS: Patients receiving AI therapy have an increased incidence of trigger finger. The outcomes of treatment are equivalent between AI and non-AI trigger finger populations. However, steroid therapy is more likely to fail in patients who require switching of regimens because of significant musculoskeletal symptoms. Poorly controlled diabetes was also an independent factor for compromised steroid treatment of trigger finger. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Spectral Computed Tomography Contrast Study: Demonstration of the Avian Cardiovascular Anatomy and Function.

As part of the cardiovascular examination, all birds underwent clinical and echocardiographic examinations. Radiographs and blood samples were taken. Each bird was premedicated with midazolam and medetomidin and anesthetized with inhalation anesthesia using isoflurane. We performed computed tomographic angiography (CTA) after intravenous injection of 1 to 2 mL contrast agent per kg followed by a 1 mL saline solution flush. We were been able to identify the arteries that previous studies revealed to be most likely affected by atherosclerotic lesions: the aorta, both pulmonary arteries, and both brachiocephalic trunks. CTA was safe and is of potential diagnostic value in birds.

Symptom Duration and Diabetic Control Influence Success of Steroid Injection in Trigger Finger.

BACKGROUND: Trigger finger is one of the most common hand abnormalities, with a prevalence of 2 percent of the general population. Conservative treatment with corticosteroid injections at the A1 pulley has been shown to be a cost-effective first-line treatment. However, additional patient factors have not fully been described regarding steroid injection efficacy. The authors hypothesize that patients presenting with longer chronicity of symptoms before treatment and elevated blood glucose would have reduced success rates of steroid injection therapy. METHODS: A retrospective chart review of 297 patients at a single institution was performed between 2013 and 2019. Patients were included if they presented with the diagnosis of trigger finger and were treated with initial corticosteroid injection at the A1 pulley. RESULTS: Steroid injection therapy alone was successful in 65 percent of patients. Patients received on average of 1.61 steroid injections. Patients who failed treatment received an average of 1.85 injections compared to 1.49 for those who had successful corticosteroid injection therapy ( p = 0.001). Presence of ipsilateral hand disease was associated with significant increase in failure of steroid injections (43.4 percent versus 30.8 percent; p = 0.032). Diabetic patients with hemoglobin A1c levels greater than 6.5 percent had a significantly higher rate of failing steroid injection therapy (71.9 percent versus 38.1 percent; p < 0.001). Patients who presented with greater than 2.5 months of symptoms had a higher failure rate of corticosteroid therapy (40.4 percent versus 29.5 percent; p = 0.048). CONCLUSION: Patients with a coexisting diagnosis of diabetes and a hemoglobin A1c level greater than 6.5 percent, ipsilateral concomitant hand disease, or presence of symptoms for greater than 2.5 months should be counseled regarding higher risk of failure of local corticosteroid injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Addressing Surgical Instrument Oversupply: A Focused Literature Review and Case-Study in Orthopedic Hand Surgery.

BACKGROUND: Instrument oversupply drives cost in the operating room (OR). We review previously reported methodologies for surgical instrument reduction and report a pilot methodology for optimizing instrument supply via ethnographic instrument tracking of thumb carpometacarpal (CMC) arthroplasties. Additionally, we report a cost analysis of instrument oversupply and potential savings of tray optimization methods. METHODS: Instrument utilization was tracked over 8 CMC arthroplasties conducted by 2 surgeons at an ambulatory surgery center of a large academic hospital. An optimized supply methodology was designed. A cost analysis was conducted using health-system-specific data and previously published research. RESULTS: After tracking instrument use in 8 CMC arthroplasties, a cumulative total of 59 out of the 120 instruments in the Hand & Foot (H&F) tray were used in at least 1 case. Two instruments were used in all cases, and another 20 instruments were used in at least 50% of the cases. Using a reduced tray with 59 instruments, potential cost savings for tray reduction in 60 cases were estimated to be $2086 without peel-packing and $2356 with peel-packing. The estimated cost savings were lower than those reported in literature due to a reduced scope and exclusion of OR time cost in the analysis. CONCLUSIONS: Instrument oversupply drives cost at our institution's ambulatory surgery center. Ethnography is a cost-effective method to track instrument utilization and determine optimal tray composition for small services but is not scalable to large health systems. The time and cost required to observe sufficient surgeries to enable supply reduction to motivate the need for more efficient methods to determine instrument utility.

Association of Lunate Morphology With Progression to Scaphoid Fracture Nonunion.

Background: The purpose of our study was to review a series of patients with scaphoid fractures to determine whether there was an association between lunate morphology and progression to delayed union or nonunion when treated operatively or nonoperatively. Secondary aims included evaluation of the relationship between lunate morphology and scaphoid fracture location. Methods: A retrospective review of all patients with a diagnosis of scaphoid fracture was performed at our institution between 2014 and 2017. Medical records and radiographs were evaluated to determine lunate morphology, scaphoid fracture location, treatment, and time to union. Differences between groups were determined using χ2 analysis with significance set at P <.05. Multiple logistic regression analyses were used to evaluate scaphoid union in the setting of lunate morphology when controlling for confounders. Results: A total of 169 patients were included; 45.0% (n = 76) of patients had type I lunate morphology, and 55.0% (n = 93) had type II. In all, 64.5% (n = 49) of patients with type I lunate and 68.8% (n = 64) with type II lunate had a fracture at the scaphoid waist. Among all patients with a scaphoid fracture, type II lunates were more likely than type I lunates to progress to nonunion when treated both operatively and nonoperatively (18.3% vs 4.0%, P = .0042). Lunate facet size was not shown to be a significant risk factor for nonunion among patients with a type II lunate (P = .4221). Conclusions: Patients with a scaphoid fracture and type II lunate morphology were more likely to progress to nonunion than patients with a type I lunate.

Return to Activities After Simultaneous Bilateral Endoscopic Carpal Tunnel Release.

BACKGROUND: Approximately 56% of patients diagnosed with carpal tunnel syndrome present with bilateral symptoms; however, few studies have investigated bilateral simultaneous endoscopic carpal tunnel release (ECTR) and postoperative effect on return to activity. The purpose of this study was to evaluate the length of recovery in patients who received bilateral simultaneous ECTR, including pain medication requirements, return to activities of daily living, return to work, and return to recreational activities. METHODS: A retrospective analysis was performed on patients who underwent bilateral ECTR by a single hand fellowship-trained surgeon from 2013 to 2019. Demographic, operative, and clinical outcomes were collected via chart review and a telephone interview. Student t tests and χ2 tests were conducted for analysis. RESULTS: Eighty patients were included in the study; 40 were successfully contacted for telephone interview follow-up. Patients reported an average of 2 days of use of postoperative narcotic pain medication and an average of 5, 7, and 19 days of return to activities of daily living, work, and recreational activities, respectively. Female patients reported more days of narcotic pain medications (1 day vs 3 days, P = .0483) and an average of longer return to work than men (9 days vs 5 days, P = .0477). Manual laborers reported longer return to work (9 days vs 5 days, P = .0500). Older patients (aged >65 years) reported longer return to recreational activities (39 days vs 11 days, P = .0189). CONCLUSIONS: Simultaneous bilateral ECTR is a successful procedure with shorter recovery times than reported previously. Female patients, manual laborers, and older patients experience a longer recovery and should be counseled appropriately.

Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head.

INTRODUCTION: Osteonecrosis of the femoral head (ONFH) can occur after traumatic injuries of the hip. Surgical treatment with total hip arthroplasty (THA) may not produce lifelong viability in younger patients. Free vascularized fibular graft (FVFG) has become a reliable method to delay or even avoid THA in this patient population by aiming to correct loss of viable bone through vascularized autologous bone transfer. The purpose of this study was to evaluate the longevity and outcomes of FVFG for traumatic hip injuries resulting in ONFH. METHODS: We performed a retrospective review of our institutional database of patients who had undergone FVFG from 1980-2006 for post-traumatic ONFH and had a minimum follow-up of 5 years. Data collected included demographics, pre-operative Urbaniak ONFH staging, Harris Hip scores (HHS), SF-12 scores, and conversion to THA. RESULTS: Seventy-two hips in 68 patients met inclusion criteria. Mean follow-up was 11.6 years (range 5.1-33.2 years). Etiology included femoral neck fracture in 36 patients (61%), hip dislocation in 7 (12%), trauma without fracture or dislocation in 11 (19%), and femoral neck nonunion in 5 (8%). The most common stage at presentation was stage IV (48 patients). Graft survival at final follow-up (mean 10.9 years) was 64%, with mean time to conversion to THA of 8.4 years in those that did not survive (36%). There was no difference between THA conversion rates in hips with pre-collapse (Stage I and II) versus impending or post-collapse (Stage III or IV) lesions (p = 0.227). In hips with surviving grafts at final follow-up, mean HHS improved from 56.7 to 77.3 (SD 24.57, range 69-93), a mean improvement of 20.6 (p < 0.001). CONCLUSIONS: Our study reveals improvement in HHS in surviving FVFG and an acceptable overall THA conversion rate at mid to long term follow-up in Urbaniak stage I through IV hips. FVFG remains a viable option for treatment in younger patients with pre- and post-collapse (stage IV) ONFH lesions secondary to hip trauma.