Avascular necrosis of the Femoral head..

Vascularized Fibula is gold standard for treatment of Avascular necrosis of hip/femoral head. A joint procedure by Orthopedic surgeon and plastic surgeon. This presentation describes FICAT classification, available options for management and steps of execution of vascularized fibula. It also showcases 3 cases successfully treated with this technique.

1. AVN HIP Dr. Noman Ahmed Prof . Rizwan Aslam

2. Definition Osteo necrosis a.k.a AVN Death of the bone and bone cells from interruption of blood supply that leads to structural changes in the femoral head,consequent collapse and secondary osteoarthritis.

3. History Konig (1888) first described the condition and coined the term Osteochondritis Dissecans Haenish (1925) first case of ischaemic necrosis of femoral head in adult Freund (1926) gave detailed description of Osteonecrosis Chandler (1948) term “coronary disease of hip” >term Chandlers disease Pietrograndi (1957) AVN due to Steroid therapy

4. ANATOMY

5. CAUSES Hypercholesterolemia Hypercoaguable states Hyperlipidemia Hyperparathyroidism Intravascular coagulation Organ transplantation Pregnancy Congenital hip dislocation Hereditary dysostosis Gaucher disease Giant cell arteritis Thrombophlebitis idiopathic Trauma Alcohol consumption Corticosteroid intake Hypercortisolism Cushing disease Hemoglobinopathies Neoplasms Cigarette smoking SLE Pancreatitis Collagen vascular disease Gout and hyperuricemia

6. FICAT CLASSIFICATION stage 0 plain film: normal MRI: normal clinical symptoms: nil stage I plain film: normal or minor osteopaenia MRI: oedema bone scan: increased uptake clinical symptoms: pain typically in the groin stage II plain film: mixed osteopenia and/or sclerosis and/or subchondral cysts, without any subchondral lucency (crescent sign: see below) MRI: geographic defect bone scan: increased uptake clinical symptoms: pain and stiffness stage III plain film:  crescent sign  and eventual cortical collapse MRI: same as plain film clinical symptoms: pain and stiffness+/- radiation to knee and limp stage IV plain film: end stage with evidence of secondary degenerative change MRI: same as plain film clinical symptoms: pain and limp

7. Femoral head is reamed up to 15 to 18mm STEP 1 STEP 2 Measurements are taken of the tunnel

8. STEP 3 Vascularized graft is harvested Avg. 9 to 11 cm STEP 4 Fibula is inserted into the tunnel & Microvascular anastamosis is done

9. Material & Methods Period: Mar 2009 till Jan 2016 Age 27 to 47 mean 33 Sex 32 males 3 females Bilateral disease in 13 cases Follow up 2 months to 6 years

10. Referral Diagnosed and staged at Orthopedic Clinic Case discussed at MDT Patient evaluation & Counselling Preoperative X ray and MRI

11. protocol Simultaneous surgery Post operative stay in ICU Heparanized for 5 days Non weight bearing donor site for 15 days, recipient limb 3 months Monthly follow up Bone Scan at 3 months

12. CASE 1

13. 18cm fibula is harvested along with its vessel

14. CASE 2

15. CASE 3

16. MARKINGS TO HARVEST FIBULA