Free Vascularized Fibular Grafting for Osteonecrosis of the Femoral Head.

Background: Osteonecrosis of the femoral head (ONFH) remains a challenging condition in orthopaedics Description: This technique integrates the procurement of the fibula and its implantation into the femoral head via a direct anterior approach. The fibular pedicle is harvested, along with its nutrient peroneal vessels. The lateral circumflex femoral vessels are then exposed. Subsequently, an anterior capsulotomy and a cortical trough are created along the femoral neck. The necrotic region is extirpated and substituted with the fibular pedicle and cancellous bone from the femoral neck. Finally, an anastomosis is formed between the peroneal vessels of the transplanted fibula and the ascending branches of the lateral circumflex femoral vessels Alternatives: Nonoperative alternatives for the treatment of ONFH include lifestyle changes like weight control, restriction of weight-bearing activities, and alcohol cessation, alongside pharmaceutical interventions that include antilipemic agents, anticoagulants, vasodilators, and bisphosphonates. Physical therapy methods such as electromagnetic stimulation, extracorporeal shock-wave therapy, and hyperbaric oxygen may also be employed. The surgical approaches to this condition cover a wide array of operations, including core decompression, precursor cell implantation, nonstructural bone grafting, nonvascularized bone grafting, vascularized iliac bone flap transfer, transtrochanteric rotational osteotomy, and porous metal implantation Rationale: FVFG theoretically not only provides potential mechanical support for the necrotic femoral head, which may help prevent collapse, but also has the potential to improve the internal circulation of the femoral head and thus provide a favorable environment for osteoblast activity and contribute to bone induction and formation Expected Outcomes: On the basis of existing research Important Tips: To safeguard the arcuate artery, it is advisable to sever the fibula with a muscle cuff measuring approximately 1 to 2 cm in length.The length of the fibula should be adjusted according to the surgical method utilized for the hip. Retain the fibula along with the peroneal arteriovenous vessels on the corresponding side, ensuring the preservation of the peroneal vessels to the greatest extent possible.To maintain ankle joint stability, it is necessary for the distal end of the fibula to be positioned at a minimum distance of 8 cm from the ankle joint following its removal.Prior to preparing the free fibula, it is important to carefully examine the side walls of the main vessels for any notable leakage. If leakage is detected, prompt repair should be performed.The period of weight-bearing should be established on the basis of postoperative radiographic follow-up in order to prevent weight-bearing too early, which can result in femoral head collapse and failure of the head preservation therapy. Acronyms and Abbreviations: CD = core decompressionCT = computed tomographyARCO = Association Research Circulation OsseousMRI = magnetic resonance imaging.