Chair of Penn Orthopaedics, Dr. L. Scott Levin, is one of the few orthopaedic surgeons in the country performing free vascularized fibular grafts (FVFG) to treat patients with avascular necrosis of the hip. An elective microsurgical procedure, free vascularized fibular grafting is an option for hip joint preservation. During this video, Dr. Levin walks through the steps of this complex surgery.
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https://bit.ly/2HIBfUS My name is uh Scott Levi. I'm the Paul B Magnusson, professor and chairman of the Department of Orthopedics at uh Penn Medicine here in Philadelphia. Today we're gonna be talking about vascularized fibular grafting to the hip. This operation was popularized by my mentor, Dr James Urbani. Uh when I was a partner of his at uh at Duke University, uh for the last 14 years, we've offered this program uh for hip preservation to patients without femoral head collapse that are candidates for core decompression and as well to provide a vascularized bone graft, the fibula to the hip. It's a biologic solution. The operation itself has had over the years some controversy as to whether it works or not. But I'd refer you to doctor articles about this in the literature and particularly for stage three patients. Uh those not stage four but stage five, but stage three without collapse. Good cartilage. We've had superb results here and have reported this in the literature as well. The likelihood that a young patient who receives a total hip, say at the age of 25 or 28 within that person's lifetime, that hip is gonna need to be revised maybe once twice, sometimes three times if we do a vascularized fibular graft, and that operation works. When the patient's 25 it's highly likely without any evidence of collapse of the femoral head, the head remains spherical or round that hip will last the rest of the patient's life, not requiring revision. The patients are operated on under general anesthesia and we use regional blocks for post op pain management. The patient is positioned in the lateral decubitus position. This is called attention to detail. And because we image the hip routinely to check on the position of reaming an excavation of the femoral head, we move our sea arm back and forth. And in order to be efficient, there's a resting place that can give us our consistent images. So we always check preoperatively, the A P and the frog leg lateral. And once we have that the C arm then gets moved cephalad and we can begin, Dr charity can begin approach to the hip and the core decompression. A poster approach is made to the hip. So I've marked out the uh anti or superior iliac spine here. And um the literature would describe the technique indicates about 10 centimeters or excuse me, you have 10 centimeters distal to that mark is where you can anticipate to find that the vessels that will be used in the anastasis lateral fem circum. Yes. So that is an important landmark to have and then I'll proceed by then, you know, the typical landmarks that I use are the superior aspect of the greater troll cancer. The post here border of the of the cancer is here, the vast and then for a typical post tier approach, I'm going to make a centimeter off of the vastest ridge. But for this procedure, we want to have access to the anti border and, and so this is typically one third proximal two thirds distal and I'll do a line that I could use if I needed to incorporate a total hip replacement, preferably through the same incision for the patient. That rarely happens. But you know, again, this is attention to detail and planning for the future if needed. The vastus lateralis is taken down a trot prosy is performed and the transverse branch of the lateral thermal circum flex vessels are isolated for microvascular and aosis femoris vastus intermedius, vastest ridge, fastest lateralis taken down Doppler, please. Ok. So here are the vessels and we'll start to take them down from anterior to posterior to get a larger vessel diameter. And these vessels will swing from going into the rectus, they'll transpose. And then doctor car is going to drill out the femoral head and the pernial artery and veni commas will come off and meet like this right here. A core decompression is performed and the femoral neck and head is usually reamed to 19 millimeters with what we call an Abanic Remer set, custom made reamers that doctor Urbani developed to sequentially core out the femoral head and excavate the head, preserving cartilage and subchondral bone. But eliminating all the avascular bone in the lesions that are seen on MRI that pin came out. OK. But you're OK. Shot. OK. Let's see here right here. This is all the craic bone off the Remer and uh we usually clean, clean the, clean the tip here. And I don't think David, we want to capture this bone. This is more necrotic. We'll take this out. And then once we start, once we start enlarging the uh diameter, we can take that good cancerous bone from the neck. All right, let's go the next size. So you can see how we've excavated Dave. That's beautiful frog and there's no extravasation of the dye, which is very important. So the neck is intact and you've gotten up subchondral and you've made a capacious space there to put the fibula. So we'll add our conventional reams of good bone and the fibula for structural support right down the middle. After that is performed, the vascularized fibular graft is harvested from the leg under tunic and control usually between seven and 8.5 centimeters of fibula with the pernial artery and venna commas are prepared, inserted in the femoral head stabilized with a pimp. You can see if we uh reflect the lateral compartment muscles. This yellow stripe here is the perennial nerve, common perennial nerve. See the vessels around it. Can you see that? Ok. And so we want to protect that and our osteotomy will be somewhere around here, but always protecting the nerve with the home and retractors. And we'll show you that a little later. Now, if you come down here, the next sequence is we're going to cut through the anterior septum. And you can see, I just went into the anterior compartment here, see how this opens up. And then we will sweep down towards the floor towards the ino membrane and identify the anti tibial bundle, neovascular bundle as we get more and more distal. Ok. This gets a little tighter. And in order to reflect the fibula, this has to be cut. You see this here. Now doug, so we're coming across the city. OK. So the fabulous split and now we can take out the malleable, no flash of bleeding because we protected the vessels. Now we're going to come up approximately same thing. Let's have that right angle. Please hold that. So the pernial vessels are protected, so slow. So the only thing that's holding us now is uh let's have AAA small scissors, please is periosteum. The bone is transected here. All right, look out. So we've measured the neck head length of seven centimeters. Pernal artery. Veno commits are here. We take all the supporting periosteum to support the peta and this will be anna to most of the lateral femoral circumplex system. We have an artery in two good veins. Here. This fibula is discarded. This fibula is discarded. We already have our bone graft in. Ok. That's a perfect fit. Right? Ok. Then we move the pedicle anteriorly here for the anastomosis and I'll take my wire. Ok. Let's have x-ray please. Here's your uh wire background university. A little piece of for the rob. Do you have a rob rod pater anywhere? Yeah. Right now here. Correct. Ok. That's ok. Ok. Here, Rob. All right. X-ray out scope in and then the microvascular Anestis is performed with the operating microscope with usually nine interrupted sutures for the artery and the veins are usually coupled with a a coupling device to co-opt the veins, one artery and two veins are usually performed. I can see see the blood starting to well up that's coming from the vascularized fibula in the mid canal. All this period and everything here is bleeding extremely well. But this now hip is then irrigated and closed over a drain or have to the American. Is that? And the leg is splendid and closed over a drain as well. The operation usually takes us about four hours and we have fluoroscopic control throughout the operation to make sure that the fibula is placed in the correct position and that the core decompression is done so that the fibula can be positioned in the center of the femoral neck and into the lesion in the femoral head. Our motto at pen orthopedics and in the Orthoplast limb salvage center is you are possible and this is possible to do providing a solution for a hip problem with the patient's own tissue that will be living a lifetime. The results are outstanding in selected patients. We work in a team and patients have been very satisfied with this procedure. Your hip is worth pen medicine.