Free Vascularized Fibular Graft for Avascular Necrosis of the Hip

• What is a free vascularized fibular graft ?
  
  A free vascularized fibular graft consists of removing dead bone that has poor blood supply from the hip (Figure 1), and replacing it with a healthy segment of vascularized (blood-rich) bone from the fibula (the smaller bone in the lower leg, as shown in Figure 2), which serves as a graft.

• Who may need to have this surgery ?
  
  The patients who undergo this procedure have avascular necrosis (AVN) of the hip. AVN is the process of necrosis (death) of an area of bone due to poor blood supply. This may result from trauma, alcoholism, long term use of steroids, or other causes. About twenty-five percent of patients develop AVN for no apparent reason. The goal of the free vascularized fibular graft is to preserve the femoral head (hip bone) rather than replace it with an artificial joint.
  
  
• What can I expect before surgery ?
  
  Several tests and procedures are performed prior to the surgery, including:
  
  1. X-rays to measure the degree of damage to the hip (the amount of dead bone).
  2. An MRI (Magnetic Resonance Imaging) to determine the extent of the AVN.
  3. A physical exam and other lab studies are obtained at the time of admission.
  
  
• Tell me about the surgery itself.
  
  The surgery is done by two teams of specialized doctors. One team works on the hip area, and the other team works on the lower leg (the area of the fibula). During the surgery, an incision is made along the hip so that the dead bone can be removed and the remaining bone may be prepared to receive the graft. An incision is made in the lower leg to remove a segment of the fibula and its attached blood vessels. The fibular segment of bone is then inserted into the hip bone, and the vessels (artery and vein) in the hip region are connected to the vessels of the fibular graft using microsurgical technique by either sutured connection or 3M vascular coupler (Figure 3). The circulation is carefully checked to insure blood flow into the hip, and the incisions are closed. A bulky dressing is applied to the lower leg to immobilize it for comfort; this is usually removed after two days. A bandage is applied to the hip.
  
  
• What can I expect after surgery ?
  
  After surgery the patient is given anticoagulants (blood thinners) which help to prevent the blood from clotting as quickly and enhance blood flow to the grafted area. The day following surgery, a physical therapist begins instruction in crutch-walking, in muscle-strengthening exercises, and in the limitation of activities that should be observed during the recuperation period. After 6 weeks, gradual weight-bearing is allowed on the operative leg, until at 6-8 months, full weight-bearing is permitted. The removal of the fibular segment does not affect later activity. The length of the hospital stay is usually five to seven days. Follow-up checks are done at 6 weeks, 3 months, 6 months and then yearly thereafter.