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n Feature Article
Free Vascularized Fibular Grafting
for Patients Receiving Postoperative
Corticosteroids
Hao Ding, MD; Sheng-Bao Chen, MD; You-Shui Gao, MD; Sen Lin, MD; Chang-Qing Zhang, MD
abstract
Full article available online at Healio.com/Orthopedics. Search: 20140401-56
Free vascularized fibular grafting (FVFG) is an effective method to treat corticosteroidinduced osteonecrosis of the femoral head (ONFH). Some patients continued to receive
maintenance doses of corticosteroids to treat the primary disease postoperatively. This
study was performed to evaluate outcomes of FVFG for corticosteroid-induced ONFH
in patients who continued to receive corticosteroids postoperatively. The authors retrospectively reviewed the records of 44 patients (78 hips) who had received corticosteroid treatment for their primary disease after FVFG. They were followed up for at least
2 years (mean, 5.6 years). Demographic details, Harris Hip scores, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and radiographic data were
collected and analyzed. The mean Harris Hip score for all hips was 70.9±9.9 points
before surgery and increased to 84±12.1 points at the latest follow-up. There were
also significant increases (P<.05) in physical component summary score and mental
component summary score. According to the latest radiographic evaluation, 49 hips
(62.8%) appeared improved, 10 hips (12.8%) appeared unchanged, and only 19 hips
(24.4%) appeared worse. Seven hips (9%) underwent total hip arthroplasty during the
follow-up period. Therefore, the results showed that FVFG was a viable method of treating corticosteroid-induced ONFH in patients who receive maintenance doses of corticosteroids postoperatively.
Figure: Preoperative anteroposterior radiograph
of the pelvis of a 26-year-old man with lupus and
stage II bilateral hip osteonecrosis.
The authors are from the Department of Orthopedic Surgery, Shanghai Sixth People’s Hospital, Jiao
Tong University, Shanghai, China.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Chang-Qing Zhang, MD, Department of Orthopedic Surgery, Shanghai Sixth People’s Hospital, Jiao Tong University, 600 Yishan Rd, Shanghai 200233, China
(zcqgk@hotmail.com).
Received: June 27, 2013; Accepted: November 8, 2013; Posted: April 15, 2014.
doi: 10.3928/01477447-20140401-56
APRIL 2014 | Volume 37 • Number 4
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C
orticosteroid-induced osteonecrosis of the femoral head (ONFH)
is a serious complication of systemic corticosteroid administration for
treatment of autoimmune diseases, such
as systemic lupus erythematosus (SLE),
nephrotic syndrome, and rheumatoid arthritis. The prevalence of ONFH in patients receiving corticosteroids has been
reported as 0.3% to 13%.1,2 The mechanisms responsible for corticosteroidinduced ONFH are highly controversial,
but may include thrombus caused by a hypercoagulable state, increases in intraosseous pressure, and fat embolism.
Most patients with ONFH require
surgical treatment for pain relief and improvement of hip joint function. Free vascularized fibular grafting (FVFG) is an
effective method of halting the progression of osteonecrosis and promoting bone
regeneration at necrotic foci. It also provides satisfactory outcomes for patients
with corticosteroid-induced ONFH.3,4
Some patients with autoimmune diseases may be receiving maintenance
doses of corticosteroids when ONFH is
first recognized. In this case, maintaining
continuous treatment of the primary disease does not permit cessation of corticosteroids after FVFG, and corticosteroids
might adversely affect postsurgical outcomes. However, there are few reports of
the effectiveness of FVFG in patients with
postoperative corticosteroid treatment.
This study was conducted to evaluate the
effect of FVFG in the treatment of ONFH
in patients who still take maintenance
doses of corticosteroids postoperatively.
Materials and Methods
Patient Selection
The study was approved by the Regional Ethics Committee of the study
hospital, and informed consent was obtained from each patient. In clinical practice, diagnoses of ONFH were based on
history, clinical evaluation, and imaging
modalities, including anteroposterior and
frog-leg lateral radiographs as well as
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magnetic resonance imaging (MRI). The
Steinberg classification was used to evaluate radiographs, and ONFH was classified
as stages 0 to VI.5 Patients with stage II,
III, and IV ONFH underwent FVFG. Before surgery, patients were evaluated by
practicing physicians to ensure that the
primary disease was under control and
that the daily dose of corticosteroids was
10 mg or less.
The authors retrospectively reviewed
the records of patients with corticosteroidinduced ONFH who received FVFG in the
study hospital from 2000 to 2011. Patients
included in this study received ongoing
maintenance corticosteroid therapy for the
primary disease for at least 6 months after
FVFG. Patients with worsening primary
disease and those whose corticosteroid
dose had exceeded 10 mg/day during the
follow-up period were excluded. Patients
who were lost to follow-up were also excluded.
Preoperative Evaluation
Preoperative assessments, including
complete blood cell count, erythrocyte
sedimentation rate, C-reactive protein assay, urea monitoring, electrocardiography,
and other tests were performed as appropriate to ensure patient fitness for surgery.
Patient demographic characteristics and
information about corticosteroid administration (route, daily dose, total cumulative dose, and duration of corticosteroid
treatment) were recorded. When multiple
corticosteroids were used, an equivalent
dose of prednisolone was calculated as a
standard for comparison. Clinical and imaging data that were recorded preoperatively included Harris Hip score (HHS),
Medical Outcomes Study (MOS) 36-Item
Short-Form Health Survey (SF-36), plain
radiographs, and MRI.
Operative Management
All surgery was performed by the
corresponding author (C.-Q.Z.) using
previously reported methods.6,7 During
surgery, histologic examination of sub-
chondral bone was performed to confirm
the diagnosis of ONFH. Postoperative
prophylactic antibiotics were used twice
a day for 3 days, and anticoagulants
were administrated for 6 weeks after the
operation. Postoperative pain was managed with nonsteroidal anti-inflammatory
drugs (NSAIDs). Patients were instructed
to avoid bearing weight on the leg that underwent FVFG for 3 months. Weight bearing was increased gradually to full weight
bearing over the next 3 months.
Follow-up
Regular follow-up was performed every 3 months for 1 year, every 6 months
for 3 years, and annually thereafter. The
end point was conversion to total hip arthroplasty (THA). During the follow-up
period, clinical and radiographic results,
information about postoperative steroid
administration, and postoperative complications were recorded.
Clinical results were evaluated using
HHS and SF-36 health surveys. Results
were considered excellent for HHS of 90
points or greater, good for HHS of 80 to
89 points, fair for HHS of 70 to 79 points,
and poor for HHS of less than 70 points.
The physical component summary score
and mental component summary score
were widely adopted to provide an overall
index of the SF-36 health survey. These
scores were calculated using norm-based
scoring methods.8,9 Higher scores represent good health-related quality of life.
Femoral heads were assigned to one of
3 categories postoperatively, based on radiographic findings. (1) The 1st category
was improved (ie, necrosis was healed
or was being replaced with new bone).
In stage II, the crescent had disappeared
or the density of the cystic lesion had increased, with trabecular formation at the
tip of the vascularized fibula. In stage III,
the collapsed lesion healed or became
more rounded, with trabecular formation
at the tip of the vascularized fibula. (2)
The 2nd category was unchanged (ie, no
change or no progression compared with
ORTHOPEDICS | Healio.com/Orthopedics
n Feature Article
the preoperative state). (3) The 3rd stage
was worse (ie, based on the stage or evidence that the femoral head had collapsed
by more than 3 mm). Evaluations were
performed independently by 2 radiologists who were blind to the clinical results.
Statistical Analysis
Statistical analysis was performed with
SPSS version 17.0 software (SPSS Inc,
Chicago, Illinois). Paired t tests were used
to compare preoperative and postoperative values. P<.05 was considered statistically significant.
Results
Forty-four patients (78 hips) met the
inclusion criteria for the study. All patients
were ethnic Chinese. Of these patients, 34
had bilateral ONFH and underwent concurrent bilateral FVFG. Patient demographic characteristics and therapeutic
regimens are summarized in the Table.
The mean follow-up time was 5.6 years
(range, 2-10 years). Primary diseases requiring corticosteroid treatment included
SLE in 22 patients (41 hips), renal disease
in 9 patients (15 hips), idiopathic thrombocytopenic purpura in 8 patients (13
hips), and dermatomyositis in 5 patients
(9 hips). According to the Steinberg classification, 19 hips were considered stage
II, 36 hips were stage III, and 23 hips
were stage IV. Seven hips (9.0%) underwent THA during the follow-up period.
Of them, 2 hips in stage III (5.6%) and 5
hips in stage IV (21.7%) were converted
to THA. Some patients with worsening
radiographs were not willing to undergo
THA, and some of them took NSAIDs
to relieve pain. They were told to avoid
walking or standing for long periods and
were advised to undergo THA when their
lives were severely affected.
All patients fully complied with rehabilitation instructions. No patients had
serious acute complications. Eight hips
had wound hematomas. Three patients
had deep venous thrombosis and were
successfully treated with oral medication.
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Table
Demographic Details
of Study Patients With
Corticosteroid-induced
Osteonecrosis of
the Femoral Head
Variable
Female:male, No.
Value
33:11
Mean duration of corticosteroid treatment
before surgery, mo
(range)
17.8 (6-48)
Mean cumulative prednisolone dose before
surgery, g (range)
9.5 (5.2-19.1)
Mean duration of
osteonecrosis of the
femoral head before
surgery, mo (range)
7.9 (1-20)
Mean age at surgery, y
(range)
27.8 (17-38)
Mean daily dose of
prednisolone after
surgery, mg (range)
5.8 (2.5-10)
Mean duration of corticosteroid treatment
after surgery, mo
(range)
28.2 (9-66)
Mean follow-up, y
(range)
5.6 (2-10)
Six limbs showed clawing of the big toe.
These patients were treated nonsurgically
and recovered gradually. No patients had
pain associated with the harvest site or
around the ankle.
Harris Hip Scoring
Clinical outcomes were evaluated with
HHS. Preoperatively, the mean HHS was
70.9±9.9 points for all hips, 80.7±3.5
points for stage II hips, 72.9±5.7 points
for stage III hips, and 60.1±8.7 points
for stage IV hips. At the last follow-up,
the mean HHS was 84±12.1 points for
all hips, 92.8±7 points for stage II hips
(P<.05), 84.4±11.9 points for stage III
hips (P<.05), and 76.3±11.1 points for
stage IV hips (P<.05) (Figure 1). The
average increase in HHS was 12.1 points
(range, -5 to 22 points) for stage II hips,
Figure 1: Preoperative and postoperative Harris
Hip score (HHS) at different stages of osteonecrosis of the femoral head.
Figure 2: Physical component summary score
(PCS) and mental component summary score
(MCS) preoperatively and at last follow-up.
11.5 points (range, -13 to 23 points) for
stage III hips, and 16.2 points (range, -8 to
38 points) for stage IV hips.
SF-36 Health Survey
All patients completed SF-36 questionnaires. The mean preoperative physical
component summary score was 76±6.3
points, and the mean preoperative mental
component summary score was 70.7±8.5
points. At the last follow-up examination,
the mean physical component summary
score was 86.6±7.8 points and the mean
mental component summary score was
79.5±11.3 points. There were significant
improvements (P<.05) in the physical
component summary score and the mental component summary score at the last
follow-up examination compared with
preoperative scores (Figure 2).
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A
B
C
D
Figure 3: Preoperative radiographs (anteroposterior position) of the pelvis of a 26-year-old man with
lupus and stage II bilateral hip osteonecrosis. The preoperative Harris Hip scores were 77 (right) and 82
(left). The patient received corticosteroid treatment at maintenance doses until the latest follow-up (A).
Preoperative magnetic resonance imaging of this patient (B). Postoperative radiographs obtained in the
anteroposterior position (C) and the frog-leg position (D) 5 years after free vascularized fibular grafting
showed stability of the articular cartilage and femoral head. The postoperative Harris Hip scores at the
latest follow-up were 94 (right) and 95 (left).
Radiographic Results
Radiographic results were evaluated
with the criteria described earlier. According to the latest radiographic evaluation, 49
hips (62.8%) appeared improved (Figure
3), 10 hips (12.8%) appeared unchanged,
and 19 hips (24.4%) appeared worse. According to the Steinberg classification, 14
stage II hips (73.7%), 23 stage III hips
(63.9%), and 12 stage IV hips (52.2%) appeared improved; 1 stage II hip (5.3%), 6
stage III hips (16.7%), and 3 stage IV hips
(13%) appeared unchanged; and 4 stage II
hips (21.1%), 7 stage III hips (19.4%), and
8 stage IV hips (34.8%) appeared worse.
Discussion
Corticosteroid-induced ONFH is a
serious complication of corticosteroid
therapy. Current treatment options for
ONFH include conservative treatment,
core decompression, proximal femoral osteotomy, vascularized bone grafting, and
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THA. The outcome of conservative treatment is usually poor with this option because of the natural history of ONFH.10
For many young patients, hip replacement
cannot be expected to last the patient’s lifetime. Therefore, attempts should be made
to save the femoral head before collapse.
Free vascularized fibular grafting has been
shown to be an effective method for treating ONFH, especially for patients with
subchondral bone collapse.11,12 During the
procedure, necrotic bone is excised, and
this may interrupt the cycle of ischemia
and intraosseous hypertension and promote
local revascularization. Then the defect is
filled with osteoinductive graft to support
the subchondral surface. After the surgery,
a period of limited weight bearing benefits
the healing construct. Yoo et al13 reviewed
81 hips that received FVFG, with a mean
follow-up period of 5.2 years, and found
that 71% had radiologic improvement. Judet and Gilbert14 assessed 68 hips, with an
average follow-up of 18 years, and found
good results in 80% of patients. Berend et
al15 found that patients with postcollapse
osteonecrosis of the femoral head benefit
from FVFG, with good overall survival of
the joint.
Generally, patients with autoimmune
disease receive high-dose corticosteroids
early in the course of disease. Subsequently, the corticosteroid dose is gradually decreased to a maintenance dose
(daily prednisolone equivalent dose is ≤10
mg) as clinical improvement is achieved.
Maintenance doses of corticosteroids can
be given for 3 months to several years.
ONFH often develops while patients are
receiving maintenance doses of corticosteroids. Once ONFH is diagnosed, patients
should undergo surgery immediately because outcomes are better at earlier stages
of ONFH. Postoperatively, these patients
should continue to take corticosteroids to
treat the primary disease.
However, corticosteroids have a harmful effect on the femoral head at many aspects. Takano-Murakami et al16 found that
supraphysiologic doses of glucocorticoids
suppressed osteoblast proliferation and the
recruitment of osteoclast precursors. Corticosteroids also stimulate bone marrow
stromal cells to develop into adipocytes
while increasing the size of fat cells.17,18
Drescher et al19 reported that methylprednisolone enhances contraction of the lateral
epiphyseal arteries of the femoral head and
reduces femoral head blood flow. In this
case, corticosteroids may have an adverse
effect on the femoral head preoperatively.
It is widely accepted that high doses of corticosteroids can lead to ONFH. However,
there are no reports on whether maintenance doses of corticosteroids affect postoperative outcomes of FVFG for the treatment of corticosteroid-induced ONFH.
Therefore, it is necessary to evaluate the
effect of FVFG in patients who still receive
corticosteroids postoperatively.
This study retrospectively reviewed
44 patients (78 hips) with corticosteroidinduced ONFH who had received cortico-
ORTHOPEDICS | Healio.com/Orthopedics
n Feature Article
steroid treatment for primary disease after
FVFG. They were followed up for at least
2 years. The results showed significant
improvement in HHS and SF-36 results
at the latest follow-up. In addition, most
of the radiographic results were improved
and the rate of conversion to THA was
very low. These data showed that FVFG
in patients who received maintenance
doses of corticosteroids postoperatively
had good outcomes. There may be 2 potential reasons for the good outcomes.
First, the postoperative steroid doses were
low. Studies found that corticosteroids adversely affect the femoral head in a dosedependent manner.20-22 Maintenance doses of corticosteroids may minimally affect
recovery from ONFH. Second, FVFG has
an excellent ability to promote new bone
regeneration and revascularization to an
extent that exceeds the harmful effects of
low-dose corticosteroids.
This study did not use a matching control group of patients who did not receive
postoperative corticosteroids. Therefore,
it was not possible to determine whether
postoperative corticosteroid administration had an adverse effect on FVFG outcomes. However, the data suggested that
FVFG is an effective method to treat
corticosteroid-induced ONFH in patients
who still receive maintenance doses of
corticosteroids postoperatively to treat the
primary disease.
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