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BACKGROUND: Minimally invasive thoracic surgery is associated with substantial pain that can impair pulmonary function. Fascial plane blocks may offer a favorable alternative to opioids, but conventional local anesthetics provide a limited duration of analgesia. We therefore tested the primary hypothesis that a mixture of liposomal bupivacaine and plain bupivacaine improves the overall benefit of analgesia score (OBAS) during the first three postoperative days compared to bupivacaine alone. Secondarily, we tested the hypotheses that liposomal bupivacaine improves respiratory mechanics, and decreases opioid consumption. METHODS: Adults scheduled for robotically or video-assisted thoracic surgery with combined ultrasound-guided pectoralis II and serratus anterior plane block were randomized to bupivacaine or bupivacaine combined with liposomal bupivacaine. OBAS was measured on postoperative days 1-3 and was analyzed with a linear mixed regression model. Postoperative respiratory mechanics were estimated using a linear mixed model. Total opioid consumption was estimated with a simple linear regression model. RESULTS: We analyzed 189 patients, of whom 95 were randomized to the treatment group and 94 to the control group. There was no significant treatment effect on total OBAS during the initial three postoperative days, with an estimated geometric mean ratio of 0.93 (95% CI: 0.76, 1.14; p = 0.485). There was no observed treatment effect on respiratory mechanics, total opioid consumption, or pain scores. Average pain scores were low in both groups. CONCLUSIONS: Liposomal bupivacaine did not improve OBAS during the initial postoperative three days following minimally invasive thoracic procedures. Furthermore, there was no improvement in respiratory mechanics, no reduction in opioid consumption, and no decrease in pain scores. Thus, the data presented here does not support the use of liposomal bupivacaine over standard bupivacaine to enhance analgesia after minimally invasive thoracic surgery. SUMMARY STATEMENT: For minimally invasive thoracic procedures, addition of liposomal bupivacaine to plain bupivacaine for thoracic fascial plane blocks does not improve OBAS, reduce opioid requirements, improve postoperative respiratory mechanics, or decrease pain scores.
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BACKGROUND: Minimally invasive cardiac surgery provokes substantial pain and therefore analgesic consumption. The effect of fascial plane blocks on analgesic efficacy and overall patient satisfaction remains unclear. We therefore tested the primary hypothesis that fascial plane blocks improve overall benefit analgesia score (OBAS) during the initial 3 days after robotically assisted mitral valve repair. Secondarily, we tested the hypotheses that blocks reduce opioid consumption and improve respiratory mechanics. METHODS: Adults scheduled for robotically assisted mitral valve repairs were randomised to combined pectoralis II and serratus anterior plane blocks or to routine analgesia. The blocks were ultrasound-guided and used a mixture of plain and liposomal bupivacaine. OBAS was measured daily on postoperative Days 1-3 and were analysed with linear mixed effects modelling. Opioid consumption was assessed with a simple linear regression model and respiratory mechanics with a linear mixed model. RESULTS: As planned, we enrolled 194 patients, with 98 assigned to blocks and 96 to routine analgesic management. There was neither time-by-treatment interaction (P=0.67) nor treatment effect on total OBAS over postoperative Days 1-3 with a median difference of 0.08 (95% confidence interval [CI]: -0.50 to 0.67; P=0.69) and an estimated ratio of geometric means of 0.98 (95% CI: 0.85-1.13; P=0.75). There was no evidence of a treatment effect on cumulative opioid consumption or respiratory mechanics. Average pain scores on each postoperative day were similarly low in both groups. CONCLUSIONS: Serratus anterior and pectoralis plane blocks did not improve postoperative analgesia, cumulative opioid consumption, or respiratory mechanics during the initial 3 days after robotically assisted mitral valve repair. CLINICAL TRIAL REGISTRATION: NCT03743194.
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Procedimientos Quirúrgicos Cardíacos , Procedimientos Quirúrgicos Robotizados , Adulto , Humanos , Analgésicos Opioides , Válvula Mitral/cirugía , Analgésicos/uso terapéutico , Dolor/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
BACKGROUND: We examined the incidence, postoperative outcomes, and patient-related factors associated with preincision cardiac arrest in patients undergoing cardiac surgery. METHODS: We retrospectively examined adult patients undergoing elective or urgent cardiac surgery at the Cleveland Clinic between 2008 and 2019. The incidence of preincision cardiac arrest, defined as arrest between induction of general anesthesia and surgical incision, was reported. In a secondary analysis, we assessed the association between preincision cardiac arrest and major postoperative outcomes. In a tertiary analysis, we used adjusted linear regression models to explore the association between preincision cardiac arrest and prespecified patient risk factors, including severe left main coronary artery stenosis, left ventricular ejection fraction, moderate/severe right ventricular dysfunction, low-flow low-gradient aortic stenosis, and moderate/severe pulmonary hypertension. RESULTS: Preincision cardiac arrests occurred in 75 of 41,238 (incidence of 0.18%; 95% CI, 0.17-0.26) patients who had elective or urgent cardiac surgery. Successful cardiopulmonary resuscitation with return of spontaneous circulation or bridge to cardiopulmonary bypass occurred in 74 of 75 (98.6%) patients. Patients who experienced preincision cardiac arrest had significantly higher in-hospital mortality than those who did not (11% vs 2%; odds ratio [OR] (95% CI), 4.14 (1.94-8.84); P < .001). They were also more likely to suffer postoperative respiratory failure (46% vs 13%; OR [95% CI], 3.94 [2.40-6.47]; P < .001), requirement for renal replacement therapy (11% vs 2%; OR [95% CI], 3.90 [1.82-8.35]; P < .001), neurologic deficit (7% vs 2%; OR [95% CI], 2.49 (1.00-6.21); P = .05), and longer median hospital stay (15 vs 8 days; hazard ratio (HR) [95% CI], 0.68 [0.55-0.85]; P < .001). Reduced left ventricular ejection fraction (per 5% decrease) (OR [95% CI], 1.13 [1.03-1.22]; P = .006) and moderate/severe pulmonary hypertension (OR [95% CI], 3.40 [1.95-5.90]; P < .001) were identified as independent risk factors for cardiac arrest. CONCLUSIONS: Cardiac arrest after anesthetic induction is rare in cardiac surgical patients in our investigation. Though most patients are rescued, morbidity and mortality remain higher. Reduced left ventricular ejection fraction and moderate/severe pulmonary hypertension are associated with greater risk for preincision cardiac arrest.
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Procedimientos Quirúrgicos Cardíacos , Paro Cardíaco , Hipertensión Pulmonar , Adulto , Humanos , Incidencia , Volumen Sistólico , Estudios Retrospectivos , Función Ventricular Izquierda , Paro Cardíaco/diagnóstico , Paro Cardíaco/epidemiología , Paro Cardíaco/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Factores de Riesgo , Resultado del TratamientoRESUMEN
STUDY OBJECTIVE: To test the hypotheses that in adults having cardiac surgery with cardio-pulmonary bypass, perioperative hypotension increases the risk of delirium and atrial fibrillation during the initial five postoperative days. DESIGN: Sub-analysis of the DECADE multi-center randomized trial. SETTING: Patients who had cardiac surgery with cardiopulmonary bypass at the Cleveland Clinic. INTERVENTIONS: In the underlying trial, patients were randomly assigned 1:1 to dexmedetomidine or normal saline placebo. MEASUREMENTS: Intraoperative mean arterial pressures were recorded at 1-min intervals from arterial catheters or at 1-5-min intervals oscillometrically. Postoperative blood pressures were recorded every half-hour or more often. The co-primary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. Delirium was assessed twice daily during the initial 5 postoperative days while patients remained hospitalized with the Confusion Assessment Method for the intensive care unit. Assessments were made by trained research fellows who were blinded to the dexmedetomidine administration. MAIN RESULTS: There was no significant association between intraoperative hypotension and delirium, with an adjusted odds ratio of 0.94 (95% CI: 0.81, 1.09; P = 0.419) for a doubling in AUC of mean arterial pressure (MAP) <60 mmHg. An increase in intraoperative AUC of MAP <60 mmHg was not significantly associated with the odds of atrial fibrillation (adjusted odds ratio = 0.99; 95% CI: 0.87, 1.11; P = 0.819). Postoperative MAP <70 mmHg per hour 1.14 (97.5% CI: 1.04,1.26; P = 0.002) and MAP <80 mmHg per hour 1.05 (97.5%: 1.01, 1.10; P = 0.010) were significantly associated with atrial fibrillation. CONCLUSIONS: In patients having cardiac surgery with cardio-pulmonary bypass, neither intraoperative nor postoperative hypotension were associated with delirium. Postoperative hypotension was associated with atrial fibrillation, although intraoperative hypotension was not.
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Delirio , Hipotensión , Adulto , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Delirio/diagnóstico , Delirio/epidemiología , Delirio/etiología , Humanos , Hipotensión/diagnóstico , Hipotensión/epidemiología , Hipotensión/etiología , Unidades de Cuidados Intensivos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: Assess the efficacy of adding liposomal bupivacaine (LB) to bupivacaine-containing intercostal nerve blocks (ICNBs) to improve analgesia and decrease opioid consumption and hospital length of stay compared with bupivacaine-only ICNBs. DESIGN: This retrospective, observational investigation compared pain intensity scores and cumulative opioid consumption within the first 72 postoperative hours in patients who received ICNBs with bupivacaine plus LB (LB group) versus bupivacaine only (control group) after minimally invasive anatomic pulmonary resection. LB was tested for noninferiority on pain scores and opioid consumption. If LB was noninferior, superiority of LB was tested on both outcomes. SETTING: Academic tertiary care medical center. PARTICIPANTS: Adult patients undergoing minimally invasive anatomic pulmonary resection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For the secondary analysis, hospital length of stay was compared through the Cox regression model. Of 396 patients, 178 (45%) received LB and 218 (55%) did not. The mean (standard deviation) pain score was three (one) in the LB group and three (one) in the control group, with a difference of -0.10 (97.5% confidence interval [-0.39 to 0.18]; pâ¯=â¯0.41). The mean (standard deviation) cumulative opioid consumption (intravenous morphine equivalents) was 198 (208) mg in the LB group and 195 (162) mg in the control group. Treatment effect in opioid consumption was estimated at a ratio of geometric mean of 0.94 (97.5% confidence interval [0.74-1.20]; pâ¯=â¯0.56). Pain control and opioid consumption were noninferior with LB but not superior. Hospital discharge was not different between groups. CONCLUSIONS: LB with bupivacaine in ICNBs did not demonstrate superior postoperative analgesia or affect the rate of hospital discharge.
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Cirugía Torácica , Adulto , Analgésicos Opioides , Anestésicos Locales , Bupivacaína , Humanos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Estudios RetrospectivosRESUMEN
COVID-19 is extremely transmissible. Cardiopulmonary resuscitation (CPR) is associated with multiple aerosol-generating procedures including chest compression, positive pressure ventilation, and airway manipulation. Healthcare providers who perform CPR are at high risk of contracting COVID-19. CPR in patients with suspected or proven COVID-19 must be performed without compromising the safety of healthcare providers. An overview of special considerations.
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Approximately 12% to 15% of hospitalized patients with COVID-19 infection require invasive ventilation via endotracheal intubation. The key to minimizing risk of disease transmission during this aerosol-generating procedure is careful preparation, which includes having necessary equipment and medications on hand as well as an experienced intubation team who can troubleshoot any unforeseen complications. Personal protective equipment should be donned and doffed in the presence of an assistant (ie, "buddy" system).
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Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients' perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes.
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Anestesia Local/métodos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Fascia/efectos de los fármacos , Bloqueo Nervioso/métodos , Manejo del Dolor/métodos , Pared Torácica/efectos de los fármacos , Anestésicos Locales/administración & dosificación , Fascia/inervación , Humanos , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Pared Torácica/inervaciónRESUMEN
BACKGROUND: Mechanical ventilation with low tidal volumes appears to provide benefit in patients having noncardiac surgery; however, whether it is beneficial in patients having cardiac surgery is unclear. METHODS: We retrospectively examined patients having elective cardiac surgery requiring cardiopulmonary bypass through a median sternotomy approach who received mechanical ventilation with a single lumen endotracheal tube from January 2010 to mid-August 2016. Time-weighted average tidal volume (milliliter per kilogram predicted body weight [PBW]) during the duration of surgery excluding cardiopulmonary bypass was analyzed. The association between tidal volumes and postoperative oxygenation (measured by arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen ratio [PaO2/FIO2]), impaired oxygenation (PaO2/FIO2 <300), and clinical outcomes were examined. RESULTS: Of 9359 cardiac surgical patients, larger tidal volumes were associated with slightly worse postoperative oxygenation. Postoperative PaO2/FIO2 decreased an estimated 1.05% per 1 mL/kg PBW increase in tidal volume (97.5% confidence interval [CI], -1.74 to -0.37; PBon = .0005). An increase in intraoperative tidal volumes was also associated with increased odds of impaired oxygenation (odds ratio [OR; 97.5% CI]: 1.08 [1.02-1.14] per 1 mL/kg PBW increase in tidal volume; PBon = .0029), slightly longer intubation time (5% per 1 mL/kg increase in tidal volume (hazard ratio [98.33% CI], 0.95 [0.93-0.98] per 1 mL/kg PBW; PBon < .0001), and increased mortality (OR [98.33% CI], 1.34 [1.06-1.70] per 1 mL/kg PBW increase in tidal volume; PHolm = .0144). An increase in intraoperative tidal volumes was also associated with acute postoperative respiratory failure (OR [98.33% CI], 1.16 [1.03-1.32] per 1 mL/kg PBW increase in tidal volume; PHolm = .0146), but not other pulmonary complications. CONCLUSIONS: Lower time-weighted average intraoperative tidal volumes were associated with a very modest improvement in postoperative oxygenation in patients having cardiac surgery.
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Procedimientos Quirúrgicos Cardíacos/métodos , Monitoreo Intraoperatorio/métodos , Consumo de Oxígeno/fisiología , Volumen de Ventilación Pulmonar/fisiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenAsunto(s)
Reanimación Cardiopulmonar/efectos adversos , Desfibriladores/efectos adversos , Cardioversión Eléctrica/efectos adversos , Exposición Profesional/prevención & control , Traumatismos Ocupacionales/prevención & control , Adulto , Cuidadores , Femenino , Humanos , Masculino , Persona de Mediana Edad , Traumatismos Ocupacionales/etiologíaAsunto(s)
Análisis de Falla de Equipo/métodos , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Prótesis Valvulares Cardíacas/efectos adversos , Falla de Prótesis/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentaciónRESUMEN
PURPOSE OF REVIEW: The demand for well-tolerated, effective, and opioid reducing pain management has become imperative in thoracic surgery. With the recent movement away from neuraxial analgesia for thoracic surgical patients, great interest in alternative analgesic techniques of the chest wall has developed. Multiple fascial plane blocks have been developed for pain management of the lateral chest wall and we present an up-to-date review of these popular new interventions. RECENT FINDINGS: The pectoralis and serratus anterior plane blocks may offer effective analgesia of the lateral chest wall for thoracic surgical patients. The erector spinae plane block may offer more extensive analgesic coverage but requires further investigation. SUMMARY: Fascial plane blocks hold the potential for well-tolerated and effective analgesia for thoracic surgical patients as part of a multimodal regimen of pain relief. However, many questions remain regarding block characteristics. As the literature matures, more formal recommendations will be made but quality trials are needed to provide this guidance.
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Analgesia , Bloqueo Nervioso , Cirugía Torácica , Humanos , Dolor , Manejo del DolorRESUMEN
BACKGROUND: Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. METHODS: We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). RESULTS: Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. CONCLUSIONS: In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.
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Dolor Agudo/prevención & control , Analgésicos/uso terapéutico , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Glucocorticoides/uso terapéutico , Metilprednisolona/uso terapéutico , Dolor Postoperatorio/prevención & control , Dolor Agudo/diagnóstico , Dolor Agudo/etiología , Analgésicos/efectos adversos , Analgésicos Opioides/uso terapéutico , Glucocorticoides/efectos adversos , Humanos , Metilprednisolona/efectos adversos , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Use of continuous erector spinae plane (ESP) blocks for pectus excavatum repair may be a valuable alternative to thoracic epidural placement. This report describes the successful use of bilateral ESP blocks in 2 patients with complex medical histories in which thoracic epidural placement was either contraindicated or unsuccessful. The benefits of continuous ESP blocks in this subset of patients include pain control with a focus on opioid sparing, early extubation, decreased atelectasis, improved mobilization and physical therapy, and decreased length of hospital stay.
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Tórax en Embudo/cirugía , Bloqueo Nervioso/métodos , Adulto , Femenino , Humanos , Persona de Mediana Edad , Manejo del DolorAsunto(s)
Catéteres de Permanencia , Fibrosis Pulmonar Idiopática/cirugía , Músculos Intermedios de la Espalda , Trasplante de Pulmón/efectos adversos , Bloqueo Nervioso/métodos , Dolor Postoperatorio/prevención & control , Bupivacaína/administración & dosificación , Humanos , Fibrosis Pulmonar Idiopática/diagnóstico por imagen , Músculos Intermedios de la Espalda/diagnóstico por imagen , Músculos Intermedios de la Espalda/efectos de los fármacos , Trasplante de Pulmón/tendencias , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/instrumentación , Dolor Postoperatorio/etiología , Recuperación de la Función/efectos de los fármacos , Recuperación de la Función/fisiologíaAsunto(s)
Manejo de la Vía Aérea/métodos , Hemangioma Cavernoso/complicaciones , Ventilación Unipulmonar/métodos , Neoplasias de la Lengua/complicaciones , Anciano de 80 o más Años , Antiinflamatorios/uso terapéutico , Dexametasona/uso terapéutico , Femenino , Hemangioma Cavernoso/tratamiento farmacológico , Hemotórax/cirugía , Humanos , Intubación Intratraqueal , Neoplasias de la Lengua/tratamiento farmacológicoRESUMEN
BACKGROUND: Patients with severe maxillofacial trauma pose a challenge when their airways must be secured. Often, emergent surgical airways are established when largyngoscopy or fiberoptic intubation are unsuccessful. When an airway cannot be surgically established, the anesthesiologist is forced to use novel approaches to airway management, but there are few descriptions of such techniques in the literature. METHODS: After unsuccessful laryngoscopy and a failed cricothyroidotomy and tracheostomy in a patient with deforming maxillofacial trauma, a gum-elastic bougie was inserted retrograde through a tracheal defect in a cephalad manner and exited the patient's mouth. RESULTS: The patient was successfully intubated using a modified retrograde technique through a tracheal defect with a gum-elastic bougie. CONCLUSIONS: When an uncontrolled airway cannot be secured surgically and a tracheal defect is present, retrograde intubation with a gum-elastic bougie may be considered as an emergent management option.
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Traumatismos Craneocerebrales/terapia , Intubación Intratraqueal/instrumentación , Intubación Intratraqueal/métodos , Adulto , Elasticidad , Resultado Fatal , Humanos , MasculinoRESUMEN
BACKGROUND: The present study evaluates the minimum five-year results of vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. The purposes of the present study were to review the results of fibular grafting in a large series of patients and to determine the indications for this procedure. METHODS: Eighty-six patients (101 hips) were followed clinically for a minimum of five years (or until the time of death). The study group included fourteen Marcus-Enneking stage-2 hips, twenty-three stage-3 hips, and sixty-four stage-4 hips. Three patients (three hips) died from unrelated causes before the five-year evaluation, and two patients (two hips) died after the five-year evaluation. Radiographic assessment was performed with use of the Marcus-Enneking grading system, and clinical assessment was performed with use of the Harris hip-scoring system. The end point was conversion to total hip arthroplasty. Patient satisfaction was also assessed. RESULTS: Sixty-two hips (61%) survived until the time of the five-year follow-up, and forty-two hips (42%) survived until the time of the interview (at a median of eight years postoperatively). The average Harris hip score was 58 +/- 13 at the time of presentation and 80 +/- 15 at five years. Eight (57%) of the Marcus-Enneking stage-2 hips, sixteen (70%) of the stage-3 hips, and thirty-eight (59%) of the stage-4 hips survived for at least five years. Of the eighty-one living patients (including forty-one who had a successful outcome and forty who had had a failure), forty-six patients (including twenty-one who had a successful outcome and twenty-five who had had a failure) stated that they would undergo the procedure again. CONCLUSIONS: Vascularized fibular grafting may provide a chance for normal hip function in the intermediate or long term in carefully selected patients with osteonecrosis of the femoral head.