title: Failed vascularized fibular graft in treatment of osteonecrosis of the femoral head. A histopathological analysis.
abstract: OBJECTIVE
  vascularized fibular grafting has been used to treat osteonecrosis of the femoral head in younger patients. Although the results described in the literature are promising, the failure rate is still significant, especially in steroid users. This study was undertaken to learn more, on a histopathological level, about the mechanism of vascularized fibular graft failure.
  
  
  METHODS
  fifteen femoral heads removed at conversion to total hip arthroplasty were analyzed. The case load comprised 10 men and 5 women. They ranged in age from 28 to 39 years and had a median age of 35 years. The interval between the vascularized fibular implant procedure and the conversion to total hip arthroplasty ranged from 22 months to 30 months; the median interval was 26 months. All the patients were steroid users. The heads were sectioned and axial and coronal sections were taken and stained using the WHO method (hematoxylin, phloxine, saffron and Alcian green). A quantitative and qualitative analysis of graft-host interaction at the head (zone 1), neck (zone 2) and epiphysis (zone 3) was performed.
  
  
  RESULTS
  all the specimens showed recognizable collapse of the articular surface over the area of necrosis. Thirteen femoral heads showed the presence of an osteochondral flap attached only at the margins of the area of avascular necrosis, and 10 of these 13 femoral heads also showed loss of the articulating surface with an ulcer crater corresponding to the exposed area of avascular necrosis.
  
  
  CONCLUSIONS
  vascularized fibular graft failure seems to be related to a negative effect of creeping substitution: the revascularization becomes a negative force as it supports unbalanced bone resorption, which, as is well known, is enhanced by corticosteroids.
  
  
  CONCLUSIONS
  creeping substitution is an undermining force in the repair and revascularization of the necrotic area in the femoral head.
authors.affiliation: Department of Orthopaedic-lower limb, Ospedale Israelitico, Rome, Italy.
authors.forename: Maria Chiara
authors.initials: MC
authors.lastname: Meloni
authors.affiliation: Department of Orthopaedic-lower limb, Ospedale Israelitico, Rome, Italy.
authors.forename: W Russalka
authors.initials: WR
authors.lastname: Hoedemaeker
authors.affiliation: Faculty of Medicine University of Toronto, Toronto, Canada.
authors.forename: Victor
authors.initials: V
authors.lastname: Fornasier
keywords: corticosteroid; creeping substitution; femoral head; osteonecrosis; vascularized fibular graft