Original Article

The Effectiveness of Free Vascularized Fibular

Flaps in Osteonecrosis of the Femoral Head and
Neck: A Systematic Review
Cassandra A. Ligh, MD1 Jonas A. Nelson, MD1 John P. Fischer, MD1 Stephen J. Kovach, MD1
L. Scott Levin, MD, FACS1

1 Division of Plastic Surgery, Perelman Center for Advanced Medicine, Address for correspondence L. Scott Levin, MD, FACS, Department of
University of Pennsylvania, Philadelphia, Pennsylvania Orthopediac Surgery, Penn Medicine Center, University of
Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104
J Reconstr Microsurg (e-mail: Lawrence.Levin2@uphs.upenn.edu).

Abstract Background Free vascularized fibular flaps (FVFFs) are accepted surgical options to
treat osteonecrosis of the femoral head and neck (ONFHN) to prevent conversion to
total hip replacement (THR), yet many studies are single institution cohorts, with little

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generalizability.
Purpose The purpose of this study was to perform a systematic review examining the
comparative effectiveness of FVFF to treat ONFHN, particularly preventing conversion
to a THR and improving hip function/symptoms.
Methods We searched PubMed and EMBASE databases using femoral head, free
fibula, and femoral neck keywords. Articles were excluded if not translated into English,
n < 10 hips, article was a compilation/review, outcomes were not relevant, or prior to
1994. If from the same institution, we included the largest cohort and excluded others
within the same timeline. Two investigators independently reviewed articles and
reported number of patients/hips, average age/follow-up time/graft survival before
THR, Harris hip score, THR rate, complications, and radiographic progression rates.
Results We identified 128 and 157 articles from PubMed and EMBASE. After screen-
ing/duplicate removal, 21 studies were included from 14 institutions in 9 countries.
Overall, 71% were level IV evidence. The average patient number was 129, number of
Keywords hips was 166, age at surgery was 34 years, and follow-up time was 92 months. HHS
► osteonecrosis of the improved on average 21.7 points, with the number of patients requiring THR being
femoral head and 19.4%. Graft survival before THR was 5.2 years, and 47.7% of hips had radiographic
neck progression.
► systematic review Conclusions There is a significant amount of level IV evidence describing the favorable
► free vascularized role of FVFF to treat ONFHN. Although efficacious, there is a need for higher level
fibular flap evidence. The level of evidence is 3.

Osteonecrosis of the femoral head and neck (ONFHN) is a bone of the femoral head, ultimate flattening of the articular
debilitating, potentially disabling condition that typically affects cartilage, narrowing of the joint space, subsequent osteoarth-
young people younger than the age of 50 years.1–43 The natural rosis of the hip, and often progression to irreversible destruction
history of the disease begins with infarction of the subchondral of the hip joint.1–3,5–13,15–20,22,23,25,27–29,31–34,36–41,43–46

received Copyright © by Thieme Medical DOI http://dx.doi.org/

August 19, 2016 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0036-1594294.
accepted after revision New York, NY 10001, USA. ISSN 0743-684X.
October 8, 2016 Tel: +1(212) 584-4662.
FVFF in Osteonecrosis of the Femoral Head and Neck
Patients with end-stage disease present with severely restricted
range of motion and persistent worsening pain requiring total
hip replacement (THR).1,9,17,21,23,24,32,34,41,43,47–50
Although the pathogenesis is poorly understood overall, there
are a variety of direct risk factors that include trauma, radiation,
sickle cell disease, caisson disease, and myeloproliferative
disorders.3,4,10,11,23,28,33,43,51 Indirect risk factors include alco-
hol abuse, chronic corticosteroids, coagulation disorders, statins,
human immunodeficiency virus, systemic lupus erythematosus,
and pregnancy.3,4,10,11,23,28,33,43,51 Currently, no single treat-
ment has been identified that undisputedly prevents the pro-
gression of the disease. This fact only emphasizes the crucial
debate regarding the most optimal treatment algorithm for
ONFHN especially in the younger population.
Despite the absence of a universal treatment protocol,
there has been a marked improvement in the knowledge
and management of ONFHN in the most recent decades due to
the accumulation of further research on the multiple treat-
ment methods.1–4,6,8–13,15–20,22–31,33–37,39–43,51 The treat-
ment options for patients are categorized as surgical and
nonsurgical interventions. The nonsurgical treatments in-
clude restricted weight bearing protocols and pain manage-
ment, while the surgical options include core decompression
(CD) and osteotomy, nonvascularized structural grafts, elec-
trical stimulation, vascularized bone grafts, and THR or total
hip arthroplasty (THA).1,2,4,8–10,15,27,33,52,53
It is widely accepted that the goals of treatment for ONFHN in
young people are pain relief, preservation of the femoral head
natural contour, improvement of hip joint function, and avoiding
conversion to THR.1,3,5–7,10,13,16–19,23,24,27,28,31,34,36,38–40,43 De-
spite technologic advancements in the last several decades, total
hip prosthesis do not have an infinite lifetime. This is particularly
relevant since the majority of patients who are diagnosed with
ONFHN are younger than the age of 40 years and younger age
often correlates with a more active lifestyle and increased wear
on prosthetic joints.1,3,5–7,10,13,16,18,19,23,24,27,28,31,34,36,38,40,50
THA is most often reserved as a salvage procedure for those
who are suffering from end-stage disease and while it is
indicated to help restore hip joint mobility, it is often limited
in the degree of functional improvement it can return to a
young patient. Especially, important for those young patients
suffering from ONFHN is the substantial debate over the
recommended level of activity after THA, which for many
could severely affect quality of life. In addition, THA in young
patients has been associated with high rates of revision
surgery, adding to the high demand for treatment options
that delay the progression of disease and potentially prevent
the need for THA.1,9,17,21,23,24,32,34,41,43,47,48,54
Free vascularized fibular flaps (FVFFs) have been studied in
the most recent decade and have shown to be associated with
low rates of conversion to THR and increases in HHS, an
indicator of functionality, symptoms, and range of
motion.1–12,15–20,22,23,25–28,31–36,38,40–42,45,46,49,50,54–64 The
FVFF has the advantage of providing structural and mechanical
support to the femoral head and increases local vascular supply
to the femoral head and neck.
FVFF has become an accepted and viable surgical option in
the treatment of ONFHN in young patients. The majority of
Journal of Reconstructive Microsurgery
Ligh et al.
studies of FVFF to the hip have been single institution cohorts,
with little generalizability. For this systematic review, we
critically examine the effectiveness of FVFFs in the treatment
of ONFHS in young patients younger than the age of 50 years,
particularly in preventing the conversion to a THR and
improving hip function and symptoms as evident through
Harris hip scoring (HHS).
Methods
Data Sources and Search
Our group performed a systematic review utilizing two data-
bases; PubMed and EMBASE, in accordance with described
methodology.65–68 We collectively developed strict search
criteria based on keywords and subject headings as well as
inclusion criteria that were determined a priori. The following
key phrases were utilized for the search: femoral head, free
fibula, and femoral neck. In addition, the reference lists of all
included primary studies and reviews were hand searched to
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capture all relevant articles.
Study Selection, Data Abstraction, and Quality
Assessment
Two investigators independently performed the PubMed and
EMBASE database searches and subsequently reviewed the titles,
abstracts, and full articles to assess if they each met the
predetermined inclusion criteria. We standardized our search
timeline; therefore, we would include articles that were pub-
lished between January 1, 1994, and February 15, 2014. Out-
comes of interest included HHS, THA conversion rates,
complication rates, and radiographic progression rates. We
excluded articles that were not available in English, included
less than 10 studied hips, were literature reviews or compilation
articles that included outcomes were not relevant (i.e., surgical
technique article, responses/commentary, cost-effectiveness
analysis, histopathological analysis, or radiographic imaging
study), or were performed before January 1, 1994.
In the preliminary screening of articles, we found that
there were several institutions that published articles that
encompassed the same patient cohorts. To address the issue
of patient overlap, we included the article with the largest
cohort of patients and excluded those within the same time-
line of patient enrollment to minimize patient overlap within
the final cohort of patients for analysis. ►Fig. 1 illustrates our
group’s process of article screening and selection based on the
earlier description.
Data Synthesis and Analysis
After identifying the relevant articles, we collected the re-
ported outcomes and statistics that were relevant to our
research focus and constructed a detailed set of evidence
tables containing all extracted information. Data obtained
included the number of patients, number of hips, average age,
average follow-up time, HHS (pre- and postoperative), THR
conversion rate, average graft survival before THR, complica-
tions, and radiographic progression rates. There was a wide
variety of different outcomes reported. Not all articles made
comments on all categories of outcomes; consequently, we
 FVFF in Osteonecrosis of the Femoral Head and Neck
Fig. 1 Flow diagram illustrating selection of articles.
included in the data tables only what was reported by
authors. Weighted averages were calculated based on the
total number of patients in each study to control for the
varying cohort sizes.
Source of Funding
No external funding source played a role in this investigation.
Results
Study Characteristics
From the initial PubMed and EMBASE searches, we identified
128 and 157 articles, respectively. As illustrated in ►Fig. 1, after
screening the articles based on the predetermined exclusion
criteria, removing overlapping articles from the two database
queries, and excluding articles from the same institution that
encompassed the same patient population, 17 studies were
identified. The two investigators handsearched the 17 articles,
looked at all the references listed, and determined 4 more
articles for a total of 21 articles that were ultimately included
in the final analysis. The majority (71%) of articles were level IV
evidence. Articles were based on the experience of 15 different
institutions. Five of the 21 articles (23.8%) were prospective
studies. There was only one study (5%) that was a multi-
institution collaboration. Eleven (52%) of the studies were based
in North America. Nine different countries were represented in
the final analysis of studies: 10 originated in the United States, 1
in Canada, 3 in Korea, 1 in Japan, 1 in France, 1 in Taiwan, 1 in
India, 1 in Turkey, and 2 in China.
Ligh et al.
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Participant Characteristics
Examining all included articles, the average number of patients
in each study was 129 (range: 8–946) and the average number
of hips was 166 (range: 11–1,270). The total number of
patients with FVFF was 2,727 and the total number of hips
was 3,502. The weighted average age at the time of surgery was
34 years (range: 14–44) and weighted average follow-up time
was 92 months (range: 19–216). In aggregate, there were 1,638
total male patients (71%) and 656 female patients (29%).
Outcomes
All outcomes are comprehensively displayed by research
article in ►Tables 1 and 2. Overall, 15 of 21 articles (71%)
reported HHS. Patients had poor preoperative hip function in
general, with an average preoperative HHS of 62.8 (range: 38–
78). However, postoperatively, patients overall improved 21.7
points (range: 4–26.3), to an average final overall score of 84.4
(range: 73–94.9) following FVFF (see ►Table 1).
THA was ultimately performed in 19.4% (range: 0–56.4) of
patients and the average graft survival time before THA in this
cohort was 5.2 years (range: 1–10.3). This was reported in 19 of
21 studies (see ►Table 2). Eight studies performed subgroup
comparisons examining outcomes, with focuses on age and stage
of disease. Older patients were more likely to require conversion
to THA, as were patients with more advanced disease.
Several studies directly compared FVFF to other treatment
modalities. One study noted significant survival benefit for
vascularized grafts compared with nonvascularized (p < 0.05).
Further, two studies demonstrated improved outcomes in FVFF
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FVFF in Osteonecrosis of the Femoral Head and Neck Ligh et al.

Table 1 Aggregate outcomes comparing effectiveness of FVFF in improving hip function and symptoms

Authors Publication No. of No. of Average Average Harris hip score

year pts hips age (y) follow-up (pre/postoperative)
(mo) (difference in score)
Bertrand et al 2013 52 53 14 (10–26) 19 38/73 (35)
Gao et al 2013 21 42 39.6 (17–57) 42 Steinberg stage:
II: 74/93 (19)
III: 68/89 (21)
IV: 60/78 (18)
Gao et al 2013 407 578 36.7 (19–55) 60 65/86.9 (21.9)
Sabesan et al 2012 15 19 28.5 (12–46) 96 75.3/94.8 (19.5)
Eward et al 2012 61 65  50 172.8 66.4/88.6 (22.2)
Tetik et al 2011 8 11 34 (30–40) 22 66/83 (17)
Gaskill et al 2009 946 1270 32 (9–57) 99.6 N/A
Yoo et al 2008 135 151 35.5 (13–63) 166.8 72/88 (16)
Kawate et al 2007 60 71 39 (15–61) 84 56/78 (22)
Yen et al 2006 22 22 38 (28–52) Min 36 Merle d’Aubigne:

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12/18 !15/18
Kim et al 2005 19 23 43 (24–52) 50 74/82 (8)
Marciniak et al 2005 86 101 M: 40 (19–61) Median 96 58/80 (22)
F: 34 (16–54)
Plakseychuk et al 2003 46 50 44 (23–52) 60 78/82 (4)
Judet and Gilbert 2001 60 68 < 40 216 N/A
Louie et al 1999 55 63 34 (18–52) 50 57.3/83.6 (26.3)
Cho et al 1998 26 31 32 (16–48) 21 N/A
Scully et al 1998 480 (FVFG) 614 35 (18–60) Min 50 N/A
72 (CD) 98 41(18–66) Min 50
Nagi et al 1998 40 40 35.1 (14–50) 58.5 7/52 ¼ excellent
21/52 ¼ good
7/52 ¼ fair
5/52 (12.5%) ¼ poor
Sotereanos et al 1997 65 88 37 (20–52) 66 94% average improvement
IC: 79/86 (7)
IIA: 74/86 (12)
IIB: 66/82 (16)
IIC: 66/72 (6)
IIIB: 61/71 (10)
IIIC: 57/67 (10)
IVA: 45/70 (25)
IVB: 43/68 (25)
Kane et al 1996 19 20 42 (26–48) Min 24 N/A
15 19
Urbaniak et al 1995 89 103 34 (16–52) 84 Marcus criteria:
Stage II: 56/80 (24)
Stage III: 52/85 (33)
Stage IV: 41/76 (35)
Stage V: 36/96 (60)

Abbreviations: CD, core decompression; FVFF, free vascularized fibular flaps; pts, patients.

compared with CD, although both did not report significant
results (p < 0.0001 and p ¼ 0.25).
Complications were reported in 81% of the studies reviewed
with 19% not reporting any information related to complications
they encountered within their respective published studies
(see ►Table 2). These included both donor site and recipient
site complications including infection (superficial and deep),
subtrochanteric fracture, clawing of toes or contracture of flexor
hallucis longus, ability to return to sport, chronic pain, trochan-
teric bursitis, heterotopic ossification, death, peroneal

Journal of Reconstructive Microsurgery

 FVFF in Osteonecrosis of the Femoral Head and Neck Ligh et al.

Table 2 Reported rates of complication and comparison of effectiveness of FVFF to prevent conversion to THA

Authors THA conversion Average graft Complication rate

survival
% N (hips) Total (%) Breakdown
before THA (y)
Bertrand et al 10 5/52 pts Median 12 (2–16) N/A N/A
Gao et al 0 0 N/A 0 0%
Gao et al 4 23/578 N/A 2.4 0.2% infection
2.2% clawing of toes
Sabesan et al 20 3/15 pts 10.3 25 25% not able to return to their sport
Eward et al 40 26/65 8 8 2% flexor halluces longus contracture
2% ankle pain
2% heterotopic ossification
2% trochanteric bursitis
Gaskill et al N/A N/A N/A 38 17% overall
12% donor site
5% graft site
4% major complication requiring
surgical procedure or chronic
pain management

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Yoo et al 10.5 13/135 pts 8.4 18.9 15.5% clawing of toes
1.8% infection
1.6% subtrochanteric fracture
Kawate et al 18 13/71 4 12.7 12.7% re-exploration
Yen et al 9 2/22 2 4.5 4.5% toe clawing
Kim et al 13 3/23 2.6 28.8 15.8% clawing of toes
13% sensory peroneal neuropathy
Plakseychuk et al 14 7/50 7 19 6% clawing of toes
8% DVT
3% collapse of hips
2% subtrochanteric fracture
Judet et al 26 18/68 1.5 5 3% thromboembolism
2% sepsis
Louie et al 27 16/63 2.6 15 7% wound infections
2% postoperative ileus
2% reoperation
2% corneal abrasion
2% serous otitis media
Cho et al 3.3 1/30 1 6.7 6.7% pain not relieved
Nagi et al 7.5 3/40 N/A 45 10% nonunion
27.5% coxa vara
7.5% superficial wound infection
Sotereanos et al 22.7 20/88 2.5 13.7 2.2% subtrochanteric fractures
2.3% great toe clawing
9.2% DVT
Urbaniak et al 30 31/103 N/A 2 2% mortality (unrelated to operation)
Scully et al II: 11 Survival N/A N/A
III: 19 (by Ficat stage):
II: 12/111
III: 95/500
II: 35 II: 15/43
III: 79 III: 37/47
Marciniak et al et al 56 57/101 3 11 6% neurapraxia
1% intertrochanteric fracture
2% trochanteric bursitis
1% thrombophlebitis
1% skin break down
(Continued)

Journal of Reconstructive Microsurgery

FVFF in Osteonecrosis of the Femoral Head and Neck
Table 2 (Continued)
Authors THA conversion
% N (hips)
Tetik et al N/A N/A
Kane et al 20 FVFF 4/20
58 CD 11/19
Abbreviations: CD, core decompression; DVT, deep vein thrombosis; FVFF, free vascularized fibular flap; N/A, not applicable; pts, patients; THA, total
hip arthroplasty.
neuropathy, deep vein thrombosis, sepsis, reoperation, coxa
vara, and nonunion based on radiographic findings. The most
commonly reported complication was flexor halluces longus
contracture which was reported in nine articles and affected an
average of 6.1% (0.9–15.8) of patients (see ►Table 2).
Radiographic progression assessed in 12 of 21 articles
(57%) and the weighted percentage of hips that showed
progression of disease based on radiographic findings was
47.7% (range: 9–72.8%). Radiographic progression was
noted by the presence of a crescent sign, a change in the
contour of the femoral head, or loss of joint space, but each
system was slightly varied in subcategorization of stages.
There were two other articles that commented on radio-
graphic changes but did not formally report any formal
results.
Discussion
In this systematic review, we present data which demon-
strates that FVFF for ONFHN appears to afford patients with
improvement in hip function and has a low rate of conversion
to THA with currently available follow-up data. Furthermore,
studies comparing FVFF to other treatment modalities aside
from THA demonstrate that this modality may be the superior
method in treatment to delay or avoid THA. However, the vast
majority of studies available are level IV evidence, demon-
strating a significant need for higher level evidence investi-
gating this treatment modality.
Free vascularized fibula grafting for treatment of ONFHN is
an innovative treatment for this condition. The majority of
studies emerging in the past two decades are retrospective
with only 23.8% of studies presenting prospective data.
Although the technique was first described in the late
1980s, it was not widely popularized until recently, with
most early reports stemming from only several institutions.
In addition, these institutions presented multiple articles on
same cohort of patients, in an appropriate effort to closely
examine the greater efficacy of the treatment in different
subgroups of patients. In an effort to truly ascertain the
efficacy of the treatment, we limited inclusion to recent
studies so as to minimize the influence of early learning
curves in the implementation of the treatment. In addition, to
provide a more generalizable result of the data, we limited
study inclusion to only one article per institution, choosing
Journal of Reconstructive Microsurgery
Ligh et al.
Average graft Complication rate
survival
Total (%) Breakdown
before THA (y)
N/A N/A N/A
17.8 45 30% ankle pain
5% vessel thrombosis
10% proximal femur fracture
15.3 11 11% proximal femur fracture
the article that had the greatest number of patients with
appropriate follow-up data and outcomes of interest.
There were numerous inconsistencies in outcome report-
ing across included studies, as none of the outcomes of
interest was reported by all studies. Some groups did not
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report conversion to THA rates, while others did not stratify
their outcomes by HHS, instead often using other scoring
systems. There were some institutions that stratified accord-
ing to Steinberg stage or etiology of disease. When reporting
on radiographic progression, there were four different sys-
tems used (Steinberg, Pittsburgh, Ficat, and Marcus) and
while their stratification systems are similar, there are a
variety of differences that lower the utility of comparing
the studies to each other. Yet, even with these inconsistencies,
limitations and different scoring systems, we attempt to
present the most complete view of the available outcomes
data on this topic, to serve as a benchmark for FVFF for
ONFHN.
Improvement in Hip Function
HHS was the measure of hip function and symptoms used in
the majority of articles (15 of 21, 71%) and a clinically
significant improvement was noted based on this scoring
system. This system described in 1969 is based on a 100-point
scale.69 Our review demonstrates a 20-point improvement,
which typically took a patient from a poor (< 70) or fair (70–
79) hip function score into a good (80–89) or excellent range
(90–100). Other studies reported similar improvements using
other scoring methodologies. Two utilized Merle d’Aubigne
scoring. Judet and Gilbert reported 52% of their 68 hips were
found to be good or very good based on postoperative Merle
d’Aubigne scores of 17 to 18 points for very good and 15 to 16
for good.20 Yen et al focused on the score changes after
surgery and reported an improvement in Merle d’Aubigne
score from 12 to 15 points postoperatively.38 The degree of
improvement expected or seen after THA compared with
FVFF is difficult to assess due to several reasons. First, studies
are not standardized in how long patients are followed
postoperatively after THA, which allows for a variety in
HHS postoperative scores. Second, there are a variety of
surgical techniques for primary THA and many groups report
different protocols that are difficult to control for. Most
published articles report an improvement in HHS ranging
 FVFF in Osteonecrosis of the Femoral Head and Neck Ligh et al.

from anywhere from 22 to 51 points,70–74 yet there are no groups universally recognized that progression was noted by
articles that directly compare the HHS between the two the presence of a crescent sign, a change in the contour of the
surgical procedures (primary THA and FVFF). femoral head, or loss of joint space.

Total Hip Arthroplasty Conversion Rates Comparative Studies

THA conversion rates were found to be low, at just less than
20% of patients with a total time in delaying THA of more than
5 years. Importantly, the average weighted follow-up was
92 months overall. This is a positive finding, but clearly longer
follow-up needs to continue in an effort to truly determine
the long-term efficacy of preventing or delaying conversion.
Eight articles commented on subgroup analyses within
FVFF cohorts, although results were mixed in terms of
statistical significance and study focus. Patient age and dis-
ease stage were the most commonly performed subgroup
evaluations. Louie et al reported that patients older than the
age of 40 years were more likely to require conversion to THR
(p ¼ 0.01), a finding which was echoed by Yoo et al who
Of the 21 articles that were found, 4 were comparative studies
looking at FVFFs compared with either CD or nonvascularized
bone graft (see ►Table 3).8,24,52,53 There were two studies
that compared CD and FVFF directly and both found statisti-
cally significant survival benefits with patients who under-
went FVFF.52,53 The study by Scully et al was the largest
study enrolling 480 FVFF patients and 72 CD patients
(p < 0.0001).53 Kane et al reported 19 FVFF patients and 15
CD (p ¼ 0.025).52 Kim et al investigated vascularized and
nonvascularized grafts and concluded there not to be a
statistically significant difference in survival between groups
(p > 0.05). The article by Dailana et al was the only article to
compare patients with FVFF compared with those who

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demonstrated a higher survival rate in patients younger than
35 years (p ¼ 0.019).27 As a related issues, Bertrand et al
reported that mean age was statistically significant in deter-
mining whether patients would undergo secondary proce-
dures.4 In terms of disease stage, Sotereanos et al reported
that there was a higher probability of THA when patients had
greater than 30% of the femoral head affected, while Urbaniak
et al found a statistical difference (p ¼ 0.03) between the
conversion of stages II and IV hips.34,36
Radiographic Progression
There were five different radiographic classification systems
noted within the study cohort. Seven of the 12 articles used
the Steinberg classification system, while the other 5 groups
chose to use either Ficat staging, the Marcus criteria, Marcus–
Enneking staging, or the Pittsburgh classification system. All
received both CD and FVFF, but did not comment directly
on survival rates between treatment groups.8 The fact that
only four comparative articles were available highlights the
need for further cohort studies to definitely determine which
treatment is optimal for patients with ONFHN. No study to
date has performed an age-matched examination of FVFF
compared with patients who have undergone THA. Recently,
a systematic review of comparative studies was published,
and concluded that vascularized fibular flap was an optimal
surgical option compared with CD and nonvascularized fibu-
lar flap.51 This group, however, focused on specific outcomes
within these few studies and did not more generally examine
outcomes and the complication profile of this procedure.
In light of current national trends focusing on maximizing
health care resources and minimizing overall cost, there has
been recent literature looking at cost-effectiveness of surgical
intervention. Most recently, a group from Duke found FVFF

Table 3 Studies that compare vascularized graft to other common surgical option to treat ONFHN

Authors No. Groups No. Average Average THA conversion Average graft survival
(et al) of pts of hips age (y) follow-up before THA (y)
% N (hips)
(mo)
Scully (1998) 480 FVFG 614 35 (18–60) Min 50 II: 11 Survival
III: 19 (by Ficat stage):
II: 12/111
III: 95/500
72 CD 98 41(18–66) Min 50 II: 35 II: 15/43
III: 79 III: 37/47
Kane (1996) 19 FVFG 20 42 (26–48) Min 24 20 4/20 17.8
15 CD 19 58 11/19 15.3
Dailiana 27 CD-FVFG 32 34.3 (15–49) 46.2 47 15/32 96.9
(2007)
40 FVFG 54 35.7 (16–46) 47.9 20/54 73.1
Kim (2012) 19 VFG 23 43 (24–52) 50 13 3/23 2.6
19 NVFG 23 44 (23–51) 50 22 5/23 2.2

Abbreviations: CD, core decompression; FVFF, free vascularized fibular flap; NVFF, nonvascularized fibular flap; ONFHN, osteonecrosis of the femoral
head and neck; pts, patients; VFF, vascularized fibular flap.

Journal of Reconstructive Microsurgery

FVFF in Osteonecrosis of the Femoral Head and Neck
was more cost-effective than THA based on a higher average
incremental cost ($5,933 greater) and lower incremental
effectiveness score derived from quality-adjusted life years
( 0.15).54 The average lifetime cost was significantly lower
for FVFF compared with THA, which were $16,724 and
$22,657, respectively.
Limitations
Our final analysis included articles originating from a variety
of countries across three continents including North America,
Europe, and Asia, and there are likely numerous variations in
technique and reporting given this fact. Two institutions
(Duke University and Shanghai Sixth People’s Hospital)
seemed to dominate the overall literature on the topic, and
were seemingly more experienced with FVFFs based on total
case numbers and total publications on the modality. This
certainly demonstrates a degree of surgical expertise, which
could bias the overall results in favor of improved outcomes.
Furthermore, numerous modifications and general techni-
ques have been described for the procedure, and it was not
always possible to differentiate precise surgical technique in
each study. Such variations may account for variations in
outcomes. In addition, although we performed this study in a
systematic fashion, it is possible that articles with appropriate
outcomes and reporting were missed. Yet, given these limi-
tations, we have attempted to give further insight into this
important reconstructive modality for patients suffering
from ONFHN.
Conclusion
Examining available data, FVFF for the treatment of ONFHN
appears to be an efficacious treatment method, with im-
provement in hip function based on HHS and low overall
conversion to THA. These findings are based on an average of
92 months of patient follow-up and low level evidence. Our
results support that FVFF is a surgical intervention that
should be integrated into the surgical algorithm for treating
osteonecrosis of the hip. There are a variety of surgical options
when treating patients with OSFHN including FVFF, CD,
nonvascular bone graft, and TH; thus, continued research
validating its efficacy for this indication and further compar-
ison studies are crucial in improving how we as surgeons can
individually focus treatments in this targeted patient
population.
Note
Cassandra Ligh and Jonas A. Nelson contributed equally to
this work.
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