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Influence of Acetabular Coverage on Hip Survival After Free Vascularized Fibular Grafting for Femoral Head Osteonecrosis

¹ Division of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710. E-mail address: roush003{at}mc.duke.edu
² Division of Orthopaedic Surgery, Duke University Medical Center, Box 3389, Durham, NC 27710. E-mail address: olson016{at}mc.duke.edu
³ Center for Excellence in Surgical Outcomes, Division of Orthopaedic Surgery, Duke University Medical Center, Box 3094, Durham, NC 27710. E-mail address: pietr007{at}mc.duke.edu
⁴ Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, CB 7400, Chapel Hill, NC 27599-7400. E-mail address: braga{at}email.unc.edu
⁵ Division of Orthopaedic Surgery, Duke University Medical Center, Box 2912, Durham, NC 27710. E-mail address: urban006{at}mc.duke.edu

Investigation performed at the Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina

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The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Methods: We retrospectively reviewed a consecutive series of 200 hips in 160 patients with osteonecrosis of the femoral head who had undergone free vascularized fibular grafting between 1997 and 1998. The mean duration of clinical follow-up was 7.5 years. Ninety-one hips in seventy-one patients were evaluated radiographically for evidence of progression of femoral head collapse at a minimum of two years, and a mean of three years, postoperatively. We defined conversion to a total hip arthroplasty and progression of femoral head collapse as the failure end points, and we analyzed the association of the acetabular center-edge angle of Wiberg, the area and laterality of the lesion, the amount of preoperative collapse of the femoral head, and the etiology of the osteonecrosis with the likelihood of failure.

Results: Forty-eight (24%) of the 200 hips had undergone conversion to a total hip arthroplasty at the time of the final clinical follow-up. In addition, 15% (fourteen) of the ninety-one hips with sufficient radiographic follow-up demonstrated progression of femoral head collapse at the time of the final radiographic examination. Of the hips with a center-edge angle of 30°, 55% (of those with sufficient radiographic follow-up) demonstrated progressive collapse and 45% were converted to a total hip arthroplasty. In contrast, of the hips with a center-edge angle of >30°, 10% had progressive collapse (p = 0.002) and 6% were converted to a total hip arthroplasty (p < 0.001). Neither the etiology nor the size of the lesion was significantly correlated with progression of collapse or conversion to a total hip arthroplasty.

Conclusions: Patients with osteonecrosis of the femoral head and a suboptimal center-edge angle of the hip are at substantial risk for progression of femoral head collapse and conversion to a total hip arthroplasty following free vascularized fibular grafting. An estimation of the degree of hip dysplasia should be included in the preoperative assessment of patients with osteonecrosis of the femoral head for prognostic and possibly surgical planning purposes.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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